{ "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "attester_name": "Girish Dighe", "confirm_attestation": true }, "hospital_address": [ "3535 Olentangy River Rd, Columbus, OH 43214" ], "hospital_name": "Riverside Methodist Hospital", "last_updated_on": "2026-04-01", "license_information": { "license_number": "1005LH", "state": "OH" }, "location_name": [ "Riverside Methodist Hospital" ], "modifier_information": [ { "code": "50", "description": "Bilateral Procedure", "modifier_payer_information": [ { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Meritain/ASA Other Commercial Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Blue Access HMO/PPO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Traditional" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Pathway Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "HMO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "PPO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Traditional" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Options Other Commercial Plan" } ] }, { "code": "JW", "description": "Drug amount discarded/not administered to any patient", "modifier_payer_information": [ { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Meritain/ASA Other Commercial Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Blue Access HMO/PPO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Traditional" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Pathway Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "HMO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "PPO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Traditional" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Options Other Commercial Plan" } ] }, { "code": "TC", "description": "Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. It is used when only the technical portion of a test is billed, typically by hospitals, imaging centers, or independent diagnostic testing facilities", "modifier_payer_information": [ { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Aetna", "plan_name": "Meritain/ASA Other Commercial Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Blue Access HMO/PPO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Anthem Traditional" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "BCBS", "plan_name": "Pathway Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "HMO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Cigna", "plan_name": "PPO" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Exchange" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medical Mutual of Ohio", "plan_name": "Traditional" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "All Commercial Plans" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Medicaid Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Medicare Managed Care Plan" }, { "description": "The modified price is presented in the standard charge value.", "payer_name": "UnitedHealthCare", "plan_name": "Options Other Commercial Plan" } ] } ], "standard_charge_information": [ { "code_information": [ { "code": "11100001", "type": "CDM" }, { "code": "111", "type": "RC" } ], "description": "Hc Room And Bed Private Med Surg Or Gyn", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1840.8, "gross_charge": 2832.0, "setting": "both" } ] }, { "code_information": [ { "code": "11100002", "type": "CDM" }, { "code": "111", "type": "RC" } ], "description": "Hc Room And Bed Ip Only Periop Discharge", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "11200001", "type": "CDM" }, { "code": "112", "type": "RC" } ], "description": "Hc Room And Bed Private Ob", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1840.8, "gross_charge": 2832.0, "setting": "both" } ] }, { "code_information": [ { "code": "11400001", "type": "CDM" }, { "code": "114", "type": "RC" } ], "description": "Hc Room And Bed Private Psych", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1903.2, "gross_charge": 2928.0, "setting": "both" } ] }, { "code_information": [ { "code": "11700001", "type": "CDM" }, { "code": "117", "type": "RC" } ], "description": "Hc Room And Bed Private Oncology", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1840.8, "gross_charge": 2832.0, "setting": "both" } ] }, { "code_information": [ { "code": "12100001", "type": "CDM" }, { "code": "121", "type": "RC" } ], "description": "Hc Room And Bed Semi Private Med Surg Or Gyn", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1840.8, "gross_charge": 2832.0, "setting": "both" } ] }, { "code_information": [ { "code": "12200001", "type": "CDM" }, { "code": "122", "type": "RC" } ], "description": "Hc Room And Bed Semi Private Ob", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1840.8, "gross_charge": 2832.0, "setting": "both" } ] }, { "code_information": [ { "code": "12400001", "type": "CDM" }, { "code": "124", "type": "RC" } ], "description": "Hc Room And Bed Semi Private Psych", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1903.2, "gross_charge": 2928.0, "setting": "both" } ] }, { "code_information": [ { "code": "12800001", "type": "CDM" }, { "code": "128", "type": "RC" } ], "description": "Hc Room And Bed Semi Private Rehab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1840.8, "gross_charge": 2832.0, "setting": "both" } ] }, { "code_information": [ { "code": "15100001", "type": "CDM" }, { "code": "151", "type": "RC" } ], "description": "Hc Asoc Routine Care", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 980.85, "gross_charge": 1509.0, "setting": "both" } ] }, { "code_information": [ { "code": "17000001", "type": "CDM" }, { "code": "170", "type": "RC" } ], "description": "Hc Room And Bed Nursery General", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1771.25, "gross_charge": 2725.0, "setting": "both" } ] }, { "code_information": [ { "code": "17200002", "type": "CDM" }, { "code": "172", "type": "RC" } ], "description": "Hc Special Care Nursery Level 2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3054.35, "gross_charge": 4699.0, "setting": "both" } ] }, { "code_information": [ { "code": "18000001", "type": "CDM" }, { "code": "180", "type": "RC" } ], "description": "Hc Room And Bed Leave Of Absence", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "20000001", "type": "CDM" }, { "code": "200", "type": "RC" } ], "description": "Hc Room And Bed Icu", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5373.55, "gross_charge": 8267.0, "setting": "both" } ] }, { "code_information": [ { "code": "20600001", "type": "CDM" }, { "code": "206", "type": "RC" } ], "description": "Hc Room And Bed Intermediate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3285.1, "gross_charge": 5054.0, "setting": "both" } ] }, { "code_information": [ { "code": "21000001", "type": "CDM" }, { "code": "210", "type": "RC" } ], "description": "Hc Room And Bed Ccu", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5373.55, "gross_charge": 8267.0, "setting": "both" } ] }, { "code_information": [ { "code": "22000001", "type": "CDM" }, { "code": "220", "type": "RC" }, { "code": "T2101", "type": "HCPCS" } ], "description": "Hc Breast Milk Per Oz Process,Storage,Dist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2.85, "gross_charge": 4.38, "setting": "both" } ] }, { "code_information": [ { "code": "25000003", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J0702", "type": "HCPCS" } ], "description": "Hc Celestone Per 3 Mg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22.98, "gross_charge": 35.36, "setting": "both" } ] }, { "code_information": [ { "code": "25000007", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1100", "type": "HCPCS" } ], "description": "Hc Dexamehtasone 1 Mg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.68, "gross_charge": 1.04, "setting": "both" } ] }, { "code_information": [ { "code": "25000012", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J2785", "type": "HCPCS" } ], "description": "Hc Lexiscan 0.1Mg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 90.58, "gross_charge": 139.36, "setting": "both" } ] }, { "code_information": [ { "code": "25000016", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3301", "type": "HCPCS" } ], "description": "Hc Kenalog 40 Per 10 Mg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25.69, "gross_charge": 39.52, "setting": "both" } ] }, { "code_information": [ { "code": "25000021", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7325", "type": "HCPCS" } ], "description": "Hc Synvisc Per Mg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37.86, "gross_charge": 58.24, "setting": "both" } ] }, { "code_information": [ { "code": "25000031", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Dilapan", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.31, "gross_charge": 20.48, "setting": "both" } ] }, { "code_information": [ { "code": "25000034", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Hc Inhaled Nitric Oxide Per Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1013.38, "gross_charge": 1559.05, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_250", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 69.56, "gross_charge": 107.01, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J0874_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0874", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.15, "gross_charge": 0.23, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J2404_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2404", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.62, "gross_charge": 0.96, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7030_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7030", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 44.33, "gross_charge": 68.2, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7030_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7030", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 44.34, "gross_charge": 68.22, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7040_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7040", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 43.45, "gross_charge": 66.85, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7040_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7040", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42.98, "gross_charge": 66.13, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7042_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7042", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 24.82, "gross_charge": 38.18, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7042_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7042", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 23.22, "gross_charge": 35.73, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7050_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7050", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 44.15, "gross_charge": 67.92, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7050_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7050", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42.7, "gross_charge": 65.69, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7060_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7060", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 43.0, "gross_charge": 66.16, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7070_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7070", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 44.9, "gross_charge": 69.07, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7120_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7120", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42.33, "gross_charge": 65.12, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7120_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7120", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42.77, "gross_charge": 65.8, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7121_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7121", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 45.88, "gross_charge": 70.58, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7121_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7121", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 45.57, "gross_charge": 70.11, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7999_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 36.22, "gross_charge": 55.73, "setting": "both" } ] }, { "code_information": [ { "code": "25000049_J7999_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 37.82, "gross_charge": 58.19, "setting": "both" } ] }, { "code_information": [ { "code": "25000050", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Hc Desflurane Per 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.19, "gross_charge": 29.52, "setting": "both" } ] }, { "code_information": [ { "code": "25000051", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Hc Sevoflurane", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.14, "gross_charge": 29.45, "setting": "both" } ] }, { "code_information": [ { "code": "25000052", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Hc Isoflurane Per 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.12, "gross_charge": 29.41, "setting": "both" } ] }, { "code_information": [ { "code": "25000053", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Hc Hemostatic Agent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 737.8, "gross_charge": 1135.08, "setting": "both" } ] }, { "code_information": [ { "code": "25500008", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9965", "type": "HCPCS" } ], "description": "Hc Locm 100 199 Mg Per Ml Iodine Per Ml", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.08, "gross_charge": 9.36, "setting": "both" } ] }, { "code_information": [ { "code": "25500013", "type": "CDM" }, { "code": "255", "type": "RC" }, { "code": "A9577", "type": "HCPCS" } ], "description": "Hc Gadobenate Dimeglumine (Multihance), Per Ml", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.28, "gross_charge": 31.2, "setting": "both" } ] }, { "code_information": [ { "code": "25600001_256", "type": "CDM" }, { "code": "256", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.44, "gross_charge": 0.68, "setting": "both" } ] }, { "code_information": [ { "code": "25600001_J3490_256", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.44, "gross_charge": 0.68, "setting": "both" } ] }, { "code_information": [ { "code": "25600001_J7050_256", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J7050", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.44, "gross_charge": 0.68, "setting": "both" } ] }, { "code_information": [ { "code": "25600001_J9047_256", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9047", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.02, "setting": "both" } ] }, { "code_information": [ { "code": "25800001_258", "type": "CDM" }, { "code": "258", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 88.19, "gross_charge": 135.67, "setting": "both" } ] }, { "code_information": [ { "code": "25800001_J7999_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 88.69, "gross_charge": 136.45, "setting": "both" } ] }, { "code_information": [ { "code": "26000001", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96360", "type": "HCPCS" } ], "description": "Hc Hydration Therapy Initial 31 Min To 1 Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 417.95, "gross_charge": 643.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000002", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96361", "type": "HCPCS" } ], "description": "Hc Hydration Therapy Ea Addl Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 125.45, "gross_charge": 193.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000003", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96365", "type": "HCPCS" } ], "description": "Hc Infusion Therapy Initial Up To 1 Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 432.9, "gross_charge": 666.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000004", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96366", "type": "HCPCS" } ], "description": "Hc Infusion Therapy Each Addl Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 141.7, "gross_charge": 218.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000005", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96367", "type": "HCPCS" } ], "description": "Hc Infusion Therapy Sequential Drug Up To 1 Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 210.6, "gross_charge": 324.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000006", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96368", "type": "HCPCS" } ], "description": "Hc Infusion Therapy Concurrent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 229.45, "gross_charge": 353.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000007", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96369", "type": "HCPCS" } ], "description": "Hc Subcutaneous Infusion Initial Up To 1 Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 310.05, "gross_charge": 477.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000009", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "C8957", "type": "HCPCS" } ], "description": "Hc Infusion More Than 8 Hrs W Pump Nonchemo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1244.75, "gross_charge": 1915.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000010", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96373", "type": "HCPCS" } ], "description": "Hc Injection; Intra-Arterial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 226.85, "gross_charge": 349.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000011", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "M0239", "type": "HCPCS" } ], "description": "Hc Covid-19 Antibody (Bamlanivimab) Infusion Service", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 604.5, "gross_charge": 930.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000012", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "M0243", "type": "HCPCS" } ], "description": "Hc Covid-19 Antibody Casirivimab/Imdevimab (Regn-Cov2) Infusn Or Sq Inj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 604.5, "gross_charge": 930.0, "setting": "both" } ] }, { "code_information": [ { "code": "26000013", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96381", "type": "HCPCS" } ], "description": "Hc Admin Rsv Monoclonal Antibody Im", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.8, "gross_charge": 32.0, "setting": "both" } ] }, { "code_information": [ { "code": "27000001", "type": "CDM" }, { "code": "270", "type": "RC" } ], "description": "Hc Co2 Detector Easy Cap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.18, "gross_charge": 21.81, "setting": "both" } ] }, { "code_information": [ { "code": "27000002", "type": "CDM" }, { "code": "270", "type": "RC" } ], "description": "Hc Medical Supply", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11467.64, "gross_charge": 17642.52, "setting": "both" } ] }, { "code_information": [ { "code": "27100001", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Oxygen Per Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.66, "gross_charge": 4.1, "setting": "both" } ] }, { "code_information": [ { "code": "27100002", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Shoe Post Op", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 24.86, "gross_charge": 38.25, "setting": "both" } ] }, { "code_information": [ { "code": "27100003", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Supplies Splinting", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 35.7, "gross_charge": 54.92, "setting": "both" } ] }, { "code_information": [ { "code": "27100004", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Set Cervical Collar Adult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 60.06, "gross_charge": 92.4, "setting": "both" } ] }, { "code_information": [ { "code": "27100005", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0150", "type": "HCPCS" } ], "description": "Hc Collar Miami J W/Adj No Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 236.61, "gross_charge": 364.01, "setting": "both" } ] }, { "code_information": [ { "code": "27100006", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Oxygen 1St 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.52, "gross_charge": 30.03, "setting": "both" } ] }, { "code_information": [ { "code": "27100007", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Oxygen Addl 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.65, "gross_charge": 13.31, "setting": "both" } ] }, { "code_information": [ { "code": "27100008", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Neonate O2 Cannula Init 12Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 186.02, "gross_charge": 286.18, "setting": "both" } ] }, { "code_information": [ { "code": "27100010", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Neonate O2 For Oxyhood Daily", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.23, "gross_charge": 97.27, "setting": "both" } ] }, { "code_information": [ { "code": "27100012", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Artic Gel Cooling (Not Universal)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5023.66, "gross_charge": 7728.71, "setting": "both" } ] }, { "code_information": [ { "code": "27100016", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Kit Metabolic Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 156.1, "gross_charge": 240.15, "setting": "both" } ] }, { "code_information": [ { "code": "27100017", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Neonate O2 For Oxyhood Init 12Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 63.23, "gross_charge": 97.27, "setting": "both" } ] }, { "code_information": [ { "code": "27100019", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Phototherapy Per Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 221.08, "gross_charge": 340.13, "setting": "both" } ] }, { "code_information": [ { "code": "27100020", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Pillow Abduction", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 77.74, "gross_charge": 119.6, "setting": "both" } ] }, { "code_information": [ { "code": "27100021", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Special Order Garment Or Orthotic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1124.02, "gross_charge": 1729.26, "setting": "both" } ] }, { "code_information": [ { "code": "27100022", "type": "CDM" }, { "code": "274", "type": "RC" } ], "description": "Hc Elbow Immobilizer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.3, "gross_charge": 29.69, "setting": "both" } ] }, { "code_information": [ { "code": "27100023", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Traction Bucks Disp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21.29, "gross_charge": 32.76, "setting": "both" } ] }, { "code_information": [ { "code": "27100024", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Heliox Therapy Per 12 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 291.51, "gross_charge": 448.47, "setting": "both" } ] }, { "code_information": [ { "code": "27100025", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Oxygen Per Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 55.84, "gross_charge": 85.91, "setting": "both" } ] }, { "code_information": [ { "code": "27100026", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Sling Arm Horizontal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10.65, "gross_charge": 16.38, "setting": "both" } ] }, { "code_information": [ { "code": "27100027", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Valve Pep Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 73.14, "gross_charge": 112.52, "setting": "both" } ] }, { "code_information": [ { "code": "27100033", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Non Sterile Supply", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 368.77, "gross_charge": 567.34, "setting": "both" } ] }, { "code_information": [ { "code": "27100036", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Sleeve Scd Level 1 X Small And Small", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 25.51, "gross_charge": 39.25, "setting": "both" } ] }, { "code_information": [ { "code": "27100038", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Sleeve Scd Level 2 Medium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 25.67, "gross_charge": 39.49, "setting": "both" } ] }, { "code_information": [ { "code": "27100041", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Turn Assist System Regular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 319.46, "gross_charge": 491.47, "setting": "both" } ] }, { "code_information": [ { "code": "27100042", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Automatic Resuscitator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 187.68, "gross_charge": 288.74, "setting": "both" } ] }, { "code_information": [ { "code": "27100045", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Electrode Mri Ct Compatible", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 296.23, "gross_charge": 455.74, "setting": "both" } ] }, { "code_information": [ { "code": "27100053", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Eeg Electrodes Disposable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 60.45, "gross_charge": 93.0, "setting": "both" } ] }, { "code_information": [ { "code": "27100054", "type": "CDM" }, { "code": "271", "type": "RC" } ], "description": "Hc Kit Tenex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2697.67, "gross_charge": 4150.26, "setting": "both" } ] }, { "code_information": [ { "code": "27200001", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Canister Wound Vac Therapy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 283.52, "gross_charge": 436.18, "setting": "both" } ] }, { "code_information": [ { "code": "27200002", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Dressing Wound Vac Therapy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 319.46, "gross_charge": 491.47, "setting": "both" } ] }, { "code_information": [ { "code": "27200005", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Tube Tracheostomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 128.45, "gross_charge": 197.61, "setting": "both" } ] }, { "code_information": [ { "code": "27200006", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Catheter Picc Sgl Dbl Lumen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 406.79, "gross_charge": 625.83, "setting": "both" } ] }, { "code_information": [ { "code": "27200008", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Balloon Nasal Rapid Rhino", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 89.92, "gross_charge": 138.34, "setting": "both" } ] }, { "code_information": [ { "code": "27200009", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Catheter Balloon Direct Vision", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 586.34, "gross_charge": 902.06, "setting": "both" } ] }, { "code_information": [ { "code": "27200010", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Catheter Barthilon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 52.36, "gross_charge": 80.55, "setting": "both" } ] }, { "code_information": [ { "code": "27200011", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Drain Pleurevac", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 88.1, "gross_charge": 135.54, "setting": "both" } ] }, { "code_information": [ { "code": "27200022", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Needle Intraosseous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 286.31, "gross_charge": 440.48, "setting": "both" } ] }, { "code_information": [ { "code": "27200023", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Set Rapid Infuser And Tubing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 277.03, "gross_charge": 426.2, "setting": "both" } ] }, { "code_information": [ { "code": "27200028", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Tube Gastrostomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 114.47, "gross_charge": 176.11, "setting": "both" } ] }, { "code_information": [ { "code": "27200032", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cervical Ripening Balloon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.65, "gross_charge": 13.31, "setting": "both" } ] }, { "code_information": [ { "code": "27200033", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Agent Hemostatic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 509.54, "gross_charge": 783.9, "setting": "both" } ] }, { "code_information": [ { "code": "27200039", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Prisma Cassette", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 462.45, "gross_charge": 711.46, "setting": "both" } ] }, { "code_information": [ { "code": "27200046", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Catheter Lycox Camino W Tl Bolt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1711.09, "gross_charge": 2632.45, "setting": "both" } ] }, { "code_information": [ { "code": "27200078", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Needle Nerve Stim", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28.22, "gross_charge": 43.42, "setting": "both" } ] }, { "code_information": [ { "code": "27200092", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Set Uterine Tamponade Balloon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 288.44, "gross_charge": 443.76, "setting": "both" } ] }, { "code_information": [ { "code": "27200116", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C2627", "type": "HCPCS" } ], "description": "Hc Catheter Suprapubic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 125.9, "gross_charge": 193.7, "setting": "both" } ] }, { "code_information": [ { "code": "27200176", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Closure Femoral Stop", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 171.04, "gross_charge": 263.14, "setting": "both" } ] }, { "code_information": [ { "code": "27200179", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Hemostatic Surgicel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 352.5, "gross_charge": 542.3, "setting": "both" } ] }, { "code_information": [ { "code": "27200184", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1715", "type": "HCPCS" } ], "description": "Hc Needle Seed Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22.63, "gross_charge": 34.81, "setting": "both" } ] }, { "code_information": [ { "code": "27200193", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Tray Catheter Picc Midline Single Lumen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 280.27, "gross_charge": 431.19, "setting": "both" } ] }, { "code_information": [ { "code": "27200199", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Vacuum Extractor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 89.42, "gross_charge": 137.57, "setting": "both" } ] }, { "code_information": [ { "code": "27200203", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Sleeve Scd Level 03 Large And Extra Large", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 94.54, "gross_charge": 145.44, "setting": "both" } ] }, { "code_information": [ { "code": "27200232", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Sterile Supply", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 143.18, "gross_charge": 220.27, "setting": "both" } ] }, { "code_information": [ { "code": "27200234", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Clip Filshie", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 234.27, "gross_charge": 360.41, "setting": "both" } ] }, { "code_information": [ { "code": "27200279", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Laser Probe Argon Coagulator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 467.21, "gross_charge": 718.78, "setting": "both" } ] }, { "code_information": [ { "code": "27200293", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Retractor Soft Tissue", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 626.05, "gross_charge": 963.15, "setting": "both" } ] }, { "code_information": [ { "code": "27200294", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Sleeve Foot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 34.41, "gross_charge": 52.94, "setting": "both" } ] }, { "code_information": [ { "code": "27200297", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1714", "type": "HCPCS" } ], "description": "Hc Cath Transluminal Atherectomy Directional", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7676.95, "gross_charge": 11810.69, "setting": "both" } ] }, { "code_information": [ { "code": "27200298", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1724", "type": "HCPCS" } ], "description": "Hc Catheter Transluminal Atherectomy Rotational", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5211.46, "gross_charge": 8017.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200299", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1725", "type": "HCPCS" } ], "description": "Hc Catheter Transluminal Angioplasty", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 400.82, "gross_charge": 616.64, "setting": "both" } ] }, { "code_information": [ { "code": "27200300", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1726", "type": "HCPCS" } ], "description": "Hc Catheter Balloon Non Vascular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 467.4, "gross_charge": 719.08, "setting": "both" } ] }, { "code_information": [ { "code": "27200301", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1727", "type": "HCPCS" } ], "description": "Hc Catheter Balloon Tissue Dissector", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 603.14, "gross_charge": 927.9, "setting": "both" } ] }, { "code_information": [ { "code": "27200302", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1729", "type": "HCPCS" } ], "description": "Hc Catheter Drainage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 147.31, "gross_charge": 226.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200305", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1730", "type": "HCPCS" } ], "description": "Hc Cath Ep Dx Not 3D Up To 19 Electrodes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 652.51, "gross_charge": 1003.86, "setting": "both" } ] }, { "code_information": [ { "code": "27200306", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1731", "type": "HCPCS" } ], "description": "Hc Cath Ep Dx Not 3D 20 Or More Electrodes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4012.78, "gross_charge": 6173.5, "setting": "both" } ] }, { "code_information": [ { "code": "27200307", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1732", "type": "HCPCS" } ], "description": "Hc Catheter Ep Dx Ablation 3D Or Vector Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3684.48, "gross_charge": 5668.43, "setting": "both" } ] }, { "code_information": [ { "code": "27200308", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1733", "type": "HCPCS" } ], "description": "Hc Catheter Ep Dx Ablation Not 3D Or Vector Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11075.79, "gross_charge": 17039.67, "setting": "both" } ] }, { "code_information": [ { "code": "27200309", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1750", "type": "HCPCS" } ], "description": "Hc Catheter Dialysis Long Term", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 441.93, "gross_charge": 679.89, "setting": "both" } ] }, { "code_information": [ { "code": "27200312", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Catheter Infusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 395.68, "gross_charge": 608.74, "setting": "both" } ] }, { "code_information": [ { "code": "27200317", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1752", "type": "HCPCS" } ], "description": "Hc Catheter Dialysis Short Term", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 355.31, "gross_charge": 546.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200321", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1753", "type": "HCPCS" } ], "description": "Hc Catheter Intravascular Ultrasound", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1517.26, "gross_charge": 2334.24, "setting": "both" } ] }, { "code_information": [ { "code": "27200322", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1754", "type": "HCPCS" } ], "description": "Hc Catheter Intradiscal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1496.03, "gross_charge": 2301.58, "setting": "both" } ] }, { "code_information": [ { "code": "27200324", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Catheter Thrombectomy Embolectomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6812.62, "gross_charge": 10480.95, "setting": "both" } ] }, { "code_information": [ { "code": "27200326", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1758", "type": "HCPCS" } ], "description": "Hc Catheter Ureteral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3357.7, "gross_charge": 5165.7, "setting": "both" } ] }, { "code_information": [ { "code": "27200327", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1759", "type": "HCPCS" } ], "description": "Hc Catheter Intracardiac Echo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4352.69, "gross_charge": 6696.44, "setting": "both" } ] }, { "code_information": [ { "code": "27200328", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1766", "type": "HCPCS" } ], "description": "Hc Introducer Sheath Ep Sterrable Not Peel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2290.46, "gross_charge": 3523.79, "setting": "both" } ] }, { "code_information": [ { "code": "27200329", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1769", "type": "HCPCS" } ], "description": "Hc Guidewire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 189.9, "gross_charge": 292.15, "setting": "both" } ] }, { "code_information": [ { "code": "27200335", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1773", "type": "HCPCS" } ], "description": "Hc Retrieval Device For Fractured Medical Devices", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1173.17, "gross_charge": 1804.88, "setting": "both" } ] }, { "code_information": [ { "code": "27200336", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1782", "type": "HCPCS" } ], "description": "Hc Morcellator3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1280.86, "gross_charge": 1970.56, "setting": "both" } ] }, { "code_information": [ { "code": "27200337", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1814", "type": "HCPCS" } ], "description": "Hc Retinal Tamponade Device Silicone Oil", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 796.65, "gross_charge": 1225.61, "setting": "both" } ] }, { "code_information": [ { "code": "27200338", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1885", "type": "HCPCS" } ], "description": "Hc Catheter Transluminal Angioplasty Laser", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6034.32, "gross_charge": 9283.57, "setting": "both" } ] }, { "code_information": [ { "code": "27200339", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Catheter Guiding", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 479.46, "gross_charge": 737.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200340", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1892", "type": "HCPCS" } ], "description": "Hc Intro/Sheath Cardiac Electrophysiological Peel Away", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 123.36, "gross_charge": 189.78, "setting": "both" } ] }, { "code_information": [ { "code": "27200341", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1893", "type": "HCPCS" } ], "description": "Hc Intro/Sheath Cardiac Electrophysiological Not Peel Away", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1044.69, "gross_charge": 1607.21, "setting": "both" } ] }, { "code_information": [ { "code": "27200342", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Introducer Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 133.79, "gross_charge": 205.83, "setting": "both" } ] }, { "code_information": [ { "code": "27200344", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C2618", "type": "HCPCS" } ], "description": "Hc Probe Cryoablation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3472.54, "gross_charge": 5342.37, "setting": "both" } ] }, { "code_information": [ { "code": "27200346", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C2628", "type": "HCPCS" } ], "description": "Hc Catheter Occlusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1625.68, "gross_charge": 2501.04, "setting": "both" } ] }, { "code_information": [ { "code": "27200347", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C2629", "type": "HCPCS" } ], "description": "Hc Introducer Sheath Not Guid Ep Laser", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6570.7, "gross_charge": 10108.77, "setting": "both" } ] }, { "code_information": [ { "code": "27200348", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C2630", "type": "HCPCS" } ], "description": "Hc Catheter Ep Abl Not 3D Cooltip", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3985.68, "gross_charge": 6131.82, "setting": "both" } ] }, { "code_information": [ { "code": "27200351", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cannula Femoral Venous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 806.49, "gross_charge": 1240.76, "setting": "both" } ] }, { "code_information": [ { "code": "27200355", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Affinity Biohead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 415.43, "gross_charge": 639.13, "setting": "both" } ] }, { "code_information": [ { "code": "27200360", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Wire Pacing Temporary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 40.28, "gross_charge": 61.97, "setting": "both" } ] }, { "code_information": [ { "code": "27200365", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cable Pacing Temporary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 32.12, "gross_charge": 49.41, "setting": "both" } ] }, { "code_information": [ { "code": "27200366", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cannula Femoral Arterial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 698.02, "gross_charge": 1073.87, "setting": "both" } ] }, { "code_information": [ { "code": "27200367", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Introducer Single Lumen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 167.89, "gross_charge": 258.29, "setting": "both" } ] }, { "code_information": [ { "code": "27200369", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Set Cardioplegia Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 104.72, "gross_charge": 161.11, "setting": "both" } ] }, { "code_information": [ { "code": "27200374", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Catheter Iabp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1701.49, "gross_charge": 2617.67, "setting": "both" } ] }, { "code_information": [ { "code": "27200375", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cannula Retrograde", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 124.68, "gross_charge": 191.82, "setting": "both" } ] }, { "code_information": [ { "code": "27200376", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Reservoir Cellsaver", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 69.11, "gross_charge": 106.33, "setting": "both" } ] }, { "code_information": [ { "code": "27200377", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Autotransfusion Collection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 140.8, "gross_charge": 216.62, "setting": "both" } ] }, { "code_information": [ { "code": "27200378", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cannula Axillary Aortic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 95.07, "gross_charge": 146.26, "setting": "both" } ] }, { "code_information": [ { "code": "27200379", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Suture Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 223.62, "gross_charge": 344.03, "setting": "both" } ] }, { "code_information": [ { "code": "27200381", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cannula Ecmo Carmeda", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 665.44, "gross_charge": 1023.75, "setting": "both" } ] }, { "code_information": [ { "code": "27200384", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 01", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1846.2, "gross_charge": 2840.3, "setting": "both" } ] }, { "code_information": [ { "code": "27200385", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 02", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2804.85, "gross_charge": 4315.15, "setting": "both" } ] }, { "code_information": [ { "code": "27200386", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 03", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1334.86, "gross_charge": 2053.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200387", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 04", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5027.49, "gross_charge": 7734.6, "setting": "both" } ] }, { "code_information": [ { "code": "27200388", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 05", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5873.35, "gross_charge": 9035.92, "setting": "both" } ] }, { "code_information": [ { "code": "27200389", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 06", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2433.2, "gross_charge": 3743.38, "setting": "both" } ] }, { "code_information": [ { "code": "27200390", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 07", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7886.59, "gross_charge": 12133.22, "setting": "both" } ] }, { "code_information": [ { "code": "27200391", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 08", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3145.32, "gross_charge": 4838.95, "setting": "both" } ] }, { "code_information": [ { "code": "27200392", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Atrial Excluder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2312.87, "gross_charge": 3558.26, "setting": "both" } ] }, { "code_information": [ { "code": "27200393", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Aspiration Embolectomy System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 30908.11, "gross_charge": 47550.94, "setting": "both" } ] }, { "code_information": [ { "code": "27200397", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Introducer Ecmo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 85.19, "gross_charge": 131.06, "setting": "both" } ] }, { "code_information": [ { "code": "27200398", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Kit Hypertherm Chemo Delivery Sys", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7438.35, "gross_charge": 11443.62, "setting": "both" } ] }, { "code_information": [ { "code": "27200401", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Blood Pump Disposable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26857.66, "gross_charge": 41319.48, "setting": "both" } ] }, { "code_information": [ { "code": "27200425", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Kit Midline Catheter Basic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 141.86, "gross_charge": 218.24, "setting": "both" } ] }, { "code_information": [ { "code": "27200426", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Kit Midline Catheter Full", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 227.46, "gross_charge": 349.94, "setting": "both" } ] }, { "code_information": [ { "code": "27200427", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Picc Sgl/Dbl Solo W/ Sherlock", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 598.34, "gross_charge": 920.52, "setting": "both" } ] }, { "code_information": [ { "code": "27200428", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Picc Triple Lumen Solo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 635.71, "gross_charge": 978.01, "setting": "both" } ] }, { "code_information": [ { "code": "27200429", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Kit Stem Cell", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2079.51, "gross_charge": 3199.25, "setting": "both" } ] }, { "code_information": [ { "code": "27200431", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Kit Pleural Drainange Aspira", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3599.21, "gross_charge": 5537.25, "setting": "both" } ] }, { "code_information": [ { "code": "27200435", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1751", "type": "HCPCS" } ], "description": "Hc Catheter Latex Free Swan", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 120.46, "gross_charge": 185.33, "setting": "both" } ] }, { "code_information": [ { "code": "27200436", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Catheter Swan Ganz", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 135.6, "gross_charge": 208.61, "setting": "both" } ] }, { "code_information": [ { "code": "27200437", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Kit Sheath Introducer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 85.63, "gross_charge": 131.74, "setting": "both" } ] }, { "code_information": [ { "code": "27200438", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Introducer Dual Lumen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 269.0, "gross_charge": 413.84, "setting": "both" } ] }, { "code_information": [ { "code": "27200454", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Introducer Sheath Dryseal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1219.26, "gross_charge": 1875.78, "setting": "both" } ] }, { "code_information": [ { "code": "27200455", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Hmii Modular Belt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 877.84, "gross_charge": 1350.52, "setting": "both" } ] }, { "code_information": [ { "code": "27200456", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Atriclip Exclusion System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7560.14, "gross_charge": 11630.99, "setting": "both" } ] }, { "code_information": [ { "code": "27200458", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Pico Negative Pressure Wound Vac Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 482.78, "gross_charge": 742.74, "setting": "both" } ] }, { "code_information": [ { "code": "27200462", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Starter Sns W Bottle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42.33, "gross_charge": 65.12, "setting": "both" } ] }, { "code_information": [ { "code": "27200463", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Large Sns", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.85, "gross_charge": 135.15, "setting": "both" } ] }, { "code_information": [ { "code": "27200471", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Rx 272 Sterile Supply", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 97.73, "gross_charge": 150.36, "setting": "both" } ] }, { "code_information": [ { "code": "27200472", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Vad Cardiohelp (Hls Set Advanced 7.0)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29374.72, "gross_charge": 45191.87, "setting": "both" } ] }, { "code_information": [ { "code": "27200477", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C2628", "type": "HCPCS" } ], "description": "Hc Catheter Reboa", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4673.79, "gross_charge": 7190.44, "setting": "both" } ] }, { "code_information": [ { "code": "27200495", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1888", "type": "HCPCS" } ], "description": "Hc Laser Guidewire - Critical Limb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 720.77, "gross_charge": 1108.88, "setting": "both" } ] }, { "code_information": [ { "code": "27200497", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cage 13 X 36Mm 8Deg Lumbar Ant Peek Midline Ii M361308", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13195.57, "gross_charge": 20300.87, "setting": "both" } ] }, { "code_information": [ { "code": "27200498", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cath Dual Lumen Edi Nava Ventilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 479.19, "gross_charge": 737.21, "setting": "both" } ] }, { "code_information": [ { "code": "27200500", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Ecmo Circuit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5169.21, "gross_charge": 7952.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200503", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4178", "type": "HCPCS" } ], "description": "Hc Allograft 10Mm Disc Floweraminopatch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1236.57, "gross_charge": 1902.41, "setting": "both" } ] }, { "code_information": [ { "code": "27200504", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4178", "type": "HCPCS" } ], "description": "Hc Allograft 12Mm Disc Floweraminopatch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1330.41, "gross_charge": 2046.78, "setting": "both" } ] }, { "code_information": [ { "code": "27200505", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4178", "type": "HCPCS" } ], "description": "Hc Allograft 16Mm Disc Floweraminopatch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1319.09, "gross_charge": 2029.37, "setting": "both" } ] }, { "code_information": [ { "code": "27200506", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4178", "type": "HCPCS" } ], "description": "Hc Allograft 2 X 2Cm Floweramniopatch Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 399.32, "gross_charge": 614.34, "setting": "both" } ] }, { "code_information": [ { "code": "27200508", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4178", "type": "HCPCS" } ], "description": "Hc Allograft 4 X 4Cm Floweramniopatch Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 159.73, "gross_charge": 245.74, "setting": "both" } ] }, { "code_information": [ { "code": "27200511", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4178", "type": "HCPCS" } ], "description": "Hc Allograft 2 X 3Cm Floweramniopatch Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.55, "gross_charge": 408.54, "setting": "both" } ] }, { "code_information": [ { "code": "27200513", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Atriclip Exclusion Pro-V Series", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12810.88, "gross_charge": 19709.05, "setting": "both" } ] }, { "code_information": [ { "code": "27200515", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Ligasure Hand Piece", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1102.93, "gross_charge": 1696.82, "setting": "both" } ] }, { "code_information": [ { "code": "27200516", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 78.23, "gross_charge": 120.35, "setting": "both" } ] }, { "code_information": [ { "code": "27200518", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 16Mm Disc Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 528.07, "gross_charge": 812.42, "setting": "both" } ] }, { "code_information": [ { "code": "27200519", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 1.75X1.75 Cm Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 367.66, "gross_charge": 565.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200520", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 3X3.5 Cm Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 133.11, "gross_charge": 204.78, "setting": "both" } ] }, { "code_information": [ { "code": "27200521", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 3X7 Cm Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 118.46, "gross_charge": 182.25, "setting": "both" } ] }, { "code_information": [ { "code": "27200524", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1886", "type": "HCPCS" } ], "description": "Hc Catheter Extravascular Tissue Ablation Any Modality", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3948.25, "gross_charge": 6074.23, "setting": "both" } ] }, { "code_information": [ { "code": "27200525", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Fibrin Sealant Patch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2010.58, "gross_charge": 3093.2, "setting": "both" } ] }, { "code_information": [ { "code": "27200526", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Kit Multi-2 Cooled Radiofrequency Ablation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2782.2, "gross_charge": 4280.3, "setting": "both" } ] }, { "code_information": [ { "code": "27200528", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1725", "type": "HCPCS" } ], "description": "Hc Hud Cath Trans Angio C1725", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2775.28, "gross_charge": 4269.66, "setting": "both" } ] }, { "code_information": [ { "code": "27200529", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafixpl Prime 3 X 3 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 281.52, "gross_charge": 433.11, "setting": "both" } ] }, { "code_information": [ { "code": "27200531", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Glidepath Tape", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 347.98, "gross_charge": 535.35, "setting": "both" } ] }, { "code_information": [ { "code": "27200532", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Kit Neuroplasty Carpal Tunnel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2258.83, "gross_charge": 3475.12, "setting": "both" } ] }, { "code_information": [ { "code": "27200533", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Robotic Transcranial Doppler Head Cradle Pad", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 527.77, "gross_charge": 811.95, "setting": "both" } ] }, { "code_information": [ { "code": "27200534", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafixpl Prime 16Mm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 644.4, "gross_charge": 991.39, "setting": "both" } ] }, { "code_information": [ { "code": "27200535", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafixpl Prime 1.5 X 2 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 593.66, "gross_charge": 913.32, "setting": "both" } ] }, { "code_information": [ { "code": "27200536", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafixpl Prime 2 X 3 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 368.26, "gross_charge": 566.56, "setting": "both" } ] }, { "code_information": [ { "code": "27200537", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafixpl Prime 3 X 4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 228.28, "gross_charge": 351.2, "setting": "both" } ] }, { "code_information": [ { "code": "27200538", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafixpl Prime 5 X 5 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 232.93, "gross_charge": 358.36, "setting": "both" } ] }, { "code_information": [ { "code": "27200539", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1830", "type": "HCPCS" } ], "description": "Hc Powered Bone Marrow Biopsy Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 312.28, "gross_charge": 480.43, "setting": "both" } ] }, { "code_information": [ { "code": "27200540", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1748", "type": "HCPCS" } ], "description": "Hc Endoscope Single Use", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5850.05, "gross_charge": 9000.08, "setting": "both" } ] }, { "code_information": [ { "code": "27200542", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 5X7 Cm Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.18, "gross_charge": 134.13, "setting": "both" } ] }, { "code_information": [ { "code": "27200543", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 7X7 Cm Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 75.2, "gross_charge": 115.7, "setting": "both" } ] }, { "code_information": [ { "code": "27200545", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Protek Duo Cannula", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 27300.25, "gross_charge": 42000.38, "setting": "both" } ] }, { "code_information": [ { "code": "27200546", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Jada System (Vac Induced Hemorrhage Control)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2497.85, "gross_charge": 3842.85, "setting": "both" } ] }, { "code_information": [ { "code": "27200547", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Fetal Pillow", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1294.2, "gross_charge": 1991.08, "setting": "both" } ] }, { "code_information": [ { "code": "27200548", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Atriclip Exclusion Flexv Series", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3851.45, "gross_charge": 5925.31, "setting": "both" } ] }, { "code_information": [ { "code": "27200549", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Implant No Hcpcs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 471.63, "gross_charge": 725.59, "setting": "both" } ] }, { "code_information": [ { "code": "27200550", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Ecmo Nautilus And Circuit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9912.26, "gross_charge": 15249.63, "setting": "both" } ] }, { "code_information": [ { "code": "27200551", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Non-Implant Device Not Otherwise Classified", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5194.44, "gross_charge": 7991.45, "setting": "both" } ] }, { "code_information": [ { "code": "27200552", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Laminaria Cervical Dilator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23.96, "gross_charge": 36.86, "setting": "both" } ] }, { "code_information": [ { "code": "27200553", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 09", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9899.83, "gross_charge": 15230.51, "setting": "both" } ] }, { "code_information": [ { "code": "27200554", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Maze Product Level 10", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10615.62, "gross_charge": 16331.72, "setting": "both" } ] }, { "code_information": [ { "code": "27200555", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Arista Hemostat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 173.71, "gross_charge": 267.24, "setting": "both" } ] }, { "code_information": [ { "code": "27200556", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Bone Marrow Aspirate Kit With Deminerallized Bone Powder (Dbm)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3728.99, "gross_charge": 5736.91, "setting": "both" } ] }, { "code_information": [ { "code": "27200558", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1769", "type": "HCPCS" } ], "description": "Hc Rfa Sclero Guidewire - Critical Limb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1353.87, "gross_charge": 2082.88, "setting": "both" } ] }, { "code_information": [ { "code": "27200559", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Cath Thrombectomy Penumbra Lightning Aspiration Tubing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10483.28, "gross_charge": 16128.13, "setting": "both" } ] }, { "code_information": [ { "code": "27200560", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4111", "type": "HCPCS" } ], "description": "Hc Gammagraft Skin Substitute Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.42, "gross_charge": 29.88, "setting": "both" } ] }, { "code_information": [ { "code": "27200561", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial 4X4/Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 226.28, "gross_charge": 348.13, "setting": "both" } ] }, { "code_information": [ { "code": "27200562", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Argon Straight Fire Flex Probe Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 550.4, "gross_charge": 846.77, "setting": "both" } ] }, { "code_information": [ { "code": "27200563", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Ebus 21 Gauge Needle Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 321.45, "gross_charge": 494.54, "setting": "both" } ] }, { "code_information": [ { "code": "27200564", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1726", "type": "HCPCS" } ], "description": "Hc Balloon Dilator Cath Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 878.51, "gross_charge": 1351.55, "setting": "both" } ] }, { "code_information": [ { "code": "27200565", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cryo Disposable Probe Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 702.81, "gross_charge": 1081.24, "setting": "both" } ] }, { "code_information": [ { "code": "27200566", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Rigid Needle Knife Rx Triple Lumen Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 513.79, "gross_charge": 790.45, "setting": "both" } ] }, { "code_information": [ { "code": "27200567", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Ebus Balloon Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 49.43, "gross_charge": 76.04, "setting": "both" } ] }, { "code_information": [ { "code": "27200568", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Balloon Dilator Syringe Gauge Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.49, "gross_charge": 157.68, "setting": "both" } ] }, { "code_information": [ { "code": "27200569", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1729", "type": "HCPCS" } ], "description": "Hc Pleurex Cath Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2164.32, "gross_charge": 3329.72, "setting": "both" } ] }, { "code_information": [ { "code": "27200570", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1729", "type": "HCPCS" } ], "description": "Hc Thoracentesis Wayne Set Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 139.76, "gross_charge": 215.02, "setting": "both" } ] }, { "code_information": [ { "code": "27200571", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1729", "type": "HCPCS" } ], "description": "Hc Thoracentesis Kit Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 460.55, "gross_charge": 708.54, "setting": "both" } ] }, { "code_information": [ { "code": "27200572", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Forceps Endojaw Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 46.05, "gross_charge": 70.85, "setting": "both" } ] }, { "code_information": [ { "code": "27200573", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1747", "type": "HCPCS" } ], "description": "Hc Endoscope, Single-Use, Urinary Tract Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3583.4, "gross_charge": 5512.93, "setting": "both" } ] }, { "code_information": [ { "code": "27200574", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Cytology Wang Needle Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 101.83, "gross_charge": 156.66, "setting": "both" } ] }, { "code_information": [ { "code": "27200575", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Bronchoscope Disposable Flex 5.0 Plab Bronch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 588.33, "gross_charge": 905.13, "setting": "both" } ] }, { "code_information": [ { "code": "27200578", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Sealer 20Cm Tissue Enseal X1 Large Jaw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1086.62, "gross_charge": 1671.72, "setting": "both" } ] }, { "code_information": [ { "code": "27200581", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Core Dx Forceps Plab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1078.17, "gross_charge": 1658.72, "setting": "both" } ] }, { "code_information": [ { "code": "27200582", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Embolectomy Sgl Lumen Plab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 141.76, "gross_charge": 218.09, "setting": "both" } ] }, { "code_information": [ { "code": "27200583", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "A2011", "type": "HCPCS" } ], "description": "Hc Supra Sdrm Wound Matrix Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 92.27, "gross_charge": 141.95, "setting": "both" } ] }, { "code_information": [ { "code": "27200584", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 8 Sq Cm Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 156.4, "gross_charge": 240.62, "setting": "both" } ] }, { "code_information": [ { "code": "27200585", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4158", "type": "HCPCS" } ], "description": "Hc Graft 19 Sq Cm Fish-Skin Omega3 Wound Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 110.48, "gross_charge": 169.97, "setting": "both" } ] }, { "code_information": [ { "code": "27200587", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial 3X4/Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 219.63, "gross_charge": 337.89, "setting": "both" } ] }, { "code_information": [ { "code": "27200590", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Kit Single Cooled Radiofrequency Ablation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1497.46, "gross_charge": 2303.78, "setting": "both" } ] }, { "code_information": [ { "code": "27200591", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Irraflow Cassette", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6988.12, "gross_charge": 10750.95, "setting": "both" } ] }, { "code_information": [ { "code": "27200592", "type": "CDM" }, { "code": "272", "type": "RC" } ], "description": "Hc Headband Ceribell Eeg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1197.96, "gross_charge": 1843.02, "setting": "both" } ] }, { "code_information": [ { "code": "27200600", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4121", "type": "HCPCS" } ], "description": "Hc Theraskin 6 Sq Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 349.41, "gross_charge": 537.55, "setting": "both" } ] }, { "code_information": [ { "code": "27200601", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4121", "type": "HCPCS" } ], "description": "Hc Theraskin 116 Sq Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 61.89, "gross_charge": 95.22, "setting": "both" } ] }, { "code_information": [ { "code": "27200602", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4121", "type": "HCPCS" } ], "description": "Hc Theraskin 26 Sq Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 103.16, "gross_charge": 158.7, "setting": "both" } ] }, { "code_information": [ { "code": "27400001", "type": "CDM" }, { "code": "274", "type": "RC" } ], "description": "Hc Orthotic Device Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 819.05, "gross_charge": 1260.07, "setting": "both" } ] }, { "code_information": [ { "code": "27400003", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3806", "type": "HCPCS" } ], "description": "Hc Splint Dynamic Whfo Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 891.15, "gross_charge": 1371.0, "setting": "both" } ] }, { "code_information": [ { "code": "27400004", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3933", "type": "HCPCS" } ], "description": "Hc Splint Finger Pip Dip Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 415.29, "gross_charge": 638.91, "setting": "both" } ] }, { "code_information": [ { "code": "27400005", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3702", "type": "HCPCS" } ], "description": "Hc Splint Elbow Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 563.04, "gross_charge": 866.22, "setting": "both" } ] }, { "code_information": [ { "code": "27400006", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3921", "type": "HCPCS" } ], "description": "Hc Splint Dyn Hand Finger Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 656.22, "gross_charge": 1009.57, "setting": "both" } ] }, { "code_information": [ { "code": "27400007", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3913", "type": "HCPCS" } ], "description": "Hc Splint Hand Finger Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 526.44, "gross_charge": 809.9, "setting": "both" } ] }, { "code_information": [ { "code": "27400008", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3908", "type": "HCPCS" } ], "description": "Hc Splint Hand Wrist Prefab Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.85, "gross_charge": 22.85, "setting": "both" } ] }, { "code_information": [ { "code": "27400009", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4361", "type": "HCPCS" } ], "description": "Hc Walking Boot Pneum Prefab Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 85.51, "gross_charge": 131.55, "setting": "both" } ] }, { "code_information": [ { "code": "27400011", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1930", "type": "HCPCS" } ], "description": "Hc Prefab Afo W/Adj No Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 539.08, "gross_charge": 829.36, "setting": "both" } ] }, { "code_information": [ { "code": "27400013", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3030", "type": "HCPCS" } ], "description": "Hc Custom Foot Orthotic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 163.72, "gross_charge": 251.88, "setting": "both" } ] }, { "code_information": [ { "code": "27400019", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4360", "type": "HCPCS" } ], "description": "Hc Walking Boot Pneum Fit To Pt W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 554.39, "gross_charge": 852.91, "setting": "both" } ] }, { "code_information": [ { "code": "27400020", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4386", "type": "HCPCS" } ], "description": "Hc Walking Boot Non-Pneum Fit To Pt W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 340.76, "gross_charge": 524.24, "setting": "both" } ] }, { "code_information": [ { "code": "27400022", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1834", "type": "HCPCS" } ], "description": "Hc Knee Immobilizer Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1552.02, "gross_charge": 2387.73, "setting": "both" } ] }, { "code_information": [ { "code": "27400023", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3925", "type": "HCPCS" } ], "description": "Hc Splint Finger Pip Dip Spring Pf Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.95, "gross_charge": 46.08, "setting": "both" } ] }, { "code_information": [ { "code": "27400024", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3927", "type": "HCPCS" } ], "description": "Hc Splint Finger Pip Dip Stat Rng Pf Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.31, "gross_charge": 20.48, "setting": "both" } ] }, { "code_information": [ { "code": "27400027", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4350", "type": "HCPCS" } ], "description": "Hc Brace Ankle Stirrup Gel Or Air Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26.81, "gross_charge": 41.24, "setting": "both" } ] }, { "code_information": [ { "code": "27400028", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3763", "type": "HCPCS" } ], "description": "Hc Splint Ewho Rigid Wo Jnts Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1458.18, "gross_charge": 2243.36, "setting": "both" } ] }, { "code_information": [ { "code": "27400030", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1834", "type": "HCPCS" } ], "description": "Hc Brace Fracture Tibial Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1554.03, "gross_charge": 2390.81, "setting": "both" } ] }, { "code_information": [ { "code": "27400031", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1845", "type": "HCPCS" } ], "description": "Hc Brace Knee Double Upright Fit To Pt W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1792.95, "gross_charge": 2758.39, "setting": "both" } ] }, { "code_information": [ { "code": "27400033", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0120", "type": "HCPCS" } ], "description": "Hc Collar Soft Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.99, "gross_charge": 12.29, "setting": "both" } ] }, { "code_information": [ { "code": "27400034", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0150", "type": "HCPCS" } ], "description": "Hc Collar Philadelphia W/Adj No Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 225.09, "gross_charge": 346.29, "setting": "both" } ] }, { "code_information": [ { "code": "27400035", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1830", "type": "HCPCS" } ], "description": "Hc Immobilizer Knee Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 29.49, "gross_charge": 45.37, "setting": "both" } ] }, { "code_information": [ { "code": "27400036", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1930", "type": "HCPCS" } ], "description": "Hc Orthosis Ankle Foot W/Adj No Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 523.11, "gross_charge": 804.79, "setting": "both" } ] }, { "code_information": [ { "code": "27400040", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3650", "type": "HCPCS" } ], "description": "Hc Sling And Swath Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 106.48, "gross_charge": 163.82, "setting": "both" } ] }, { "code_information": [ { "code": "27400042", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3906", "type": "HCPCS" } ], "description": "Hc Splint Wrist Hand Custom Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 986.99, "gross_charge": 1518.44, "setting": "both" } ] }, { "code_information": [ { "code": "27400043", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1940", "type": "HCPCS" } ], "description": "Hc Splint Afo Dynamic Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1042.23, "gross_charge": 1603.43, "setting": "both" } ] }, { "code_information": [ { "code": "27400044", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3905", "type": "HCPCS" } ], "description": "Hc Splint Dynamic Hand Wrist Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1931.38, "gross_charge": 2971.36, "setting": "both" } ] }, { "code_information": [ { "code": "27400045", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4396", "type": "HCPCS" } ], "description": "Hc Multi Podus Boot W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 358.06, "gross_charge": 550.86, "setting": "both" } ] }, { "code_information": [ { "code": "27400046", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3808", "type": "HCPCS" } ], "description": "Hc Splint Whfo Rigid Wo Jnts Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 692.82, "gross_charge": 1065.88, "setting": "both" } ] }, { "code_information": [ { "code": "27400047", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3807", "type": "HCPCS" } ], "description": "Hc Splint Whfo Prefab With Modification W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 486.51, "gross_charge": 748.47, "setting": "both" } ] }, { "code_information": [ { "code": "27400049", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0628", "type": "HCPCS" } ], "description": "Hc Support Lumbar Sacral Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.59, "gross_charge": 71.67, "setting": "both" } ] }, { "code_information": [ { "code": "27400050", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3650", "type": "HCPCS" } ], "description": "Hc Support Shoulder Abduction Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.2, "gross_charge": 124.92, "setting": "both" } ] }, { "code_information": [ { "code": "27400051", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L8501", "type": "HCPCS" } ], "description": "Hc Tube Trach Speaking Passy Muir", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 146.43, "gross_charge": 225.28, "setting": "both" } ] }, { "code_information": [ { "code": "27400053", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3980", "type": "HCPCS" } ], "description": "Hc Brace Fracture Humeral Pf W/Adj No Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 792.65, "gross_charge": 1219.46, "setting": "both" } ] }, { "code_information": [ { "code": "27400054", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4350", "type": "HCPCS" } ], "description": "Hc Brace Ankle Stirrup Universal Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 27.29, "gross_charge": 41.98, "setting": "both" } ] }, { "code_information": [ { "code": "27400055", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0160", "type": "HCPCS" } ], "description": "Hc Aspen Vista Collar Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 73.3, "gross_charge": 112.77, "setting": "both" } ] }, { "code_information": [ { "code": "27400056", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1940", "type": "HCPCS" } ], "description": "Hc Posterior Afo Static Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1042.23, "gross_charge": 1603.43, "setting": "both" } ] }, { "code_information": [ { "code": "27400057", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3765", "type": "HCPCS" } ], "description": "Hc Splint Ewhfo Rigid W/O Jnts Cust0M", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2495.75, "gross_charge": 3839.62, "setting": "both" } ] }, { "code_information": [ { "code": "27400059", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3766", "type": "HCPCS" } ], "description": "Hc Splint Ewhfo W/Joints Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2779.94, "gross_charge": 4276.83, "setting": "both" } ] }, { "code_information": [ { "code": "27400060", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3919", "type": "HCPCS" } ], "description": "Hc Splint Ho W/O Joints Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 526.44, "gross_charge": 809.9, "setting": "both" } ] }, { "code_information": [ { "code": "27400061", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3935", "type": "HCPCS" } ], "description": "Hc Splint Fo Nontor Joint Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 430.6, "gross_charge": 662.46, "setting": "both" } ] }, { "code_information": [ { "code": "27400064", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4205", "type": "HCPCS" } ], "description": "Hc Repair Ortho Device Labor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 127.78, "gross_charge": 196.59, "setting": "both" } ] }, { "code_information": [ { "code": "27400069", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0120", "type": "HCPCS" } ], "description": "Hc Collar Cervical Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 135.77, "gross_charge": 208.88, "setting": "both" } ] }, { "code_information": [ { "code": "27400070", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0150", "type": "HCPCS" } ], "description": "Hc Collar Cervical Semi Rigid W/Adj No Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 77.87, "gross_charge": 119.8, "setting": "both" } ] }, { "code_information": [ { "code": "27400071", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L0172", "type": "HCPCS" } ], "description": "Hc Collar Cervical Semi Rigid 2 Pc Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 260.22, "gross_charge": 400.34, "setting": "both" } ] }, { "code_information": [ { "code": "27400073", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L1845", "type": "HCPCS" } ], "description": "Hc Knee Brace W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 665.54, "gross_charge": 1023.9, "setting": "both" } ] }, { "code_information": [ { "code": "27400086", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3809", "type": "HCPCS" } ], "description": "Hc Splint Whfo Prefab Wo Modification Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 29.41, "gross_charge": 45.24, "setting": "both" } ] }, { "code_information": [ { "code": "27400087", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4361", "type": "HCPCS" } ], "description": "Hc Walk Boot Prefab Off The Shelf Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.18, "gross_charge": 134.13, "setting": "both" } ] }, { "code_information": [ { "code": "27400088", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L2036", "type": "HCPCS" } ], "description": "Hc L2036 Kafo Custom Plastic Double Upright Custom", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3966.59, "gross_charge": 6102.44, "setting": "both" } ] }, { "code_information": [ { "code": "27400089", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0481", "type": "HCPCS" } ], "description": "Hc Hmii Pocket Controller", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11376.66, "gross_charge": 17502.55, "setting": "both" } ] }, { "code_information": [ { "code": "27400090", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0506", "type": "HCPCS" } ], "description": "Hc Hmii Volt Li-Lon Backup Battery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1053.49, "gross_charge": 1620.75, "setting": "both" } ] }, { "code_information": [ { "code": "27400091", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0506", "type": "HCPCS" } ], "description": "Hc 14 Volt Li-Lon Battery Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1293.14, "gross_charge": 1989.44, "setting": "both" } ] }, { "code_information": [ { "code": "27400092", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0497", "type": "HCPCS" } ], "description": "Hc 14 Volt Li-Lon Battery Clip Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1137.4, "gross_charge": 1749.85, "setting": "both" } ] }, { "code_information": [ { "code": "27400093", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0501", "type": "HCPCS" } ], "description": "Hc Pocket Controller Shower Bag Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 567.03, "gross_charge": 872.36, "setting": "both" } ] }, { "code_information": [ { "code": "27400094", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0508", "type": "HCPCS" } ], "description": "Hc Stabilization Belts", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 267.55, "gross_charge": 411.61, "setting": "both" } ] }, { "code_information": [ { "code": "27400095", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0498", "type": "HCPCS" } ], "description": "Hc Battery Holster", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 529.76, "gross_charge": 815.02, "setting": "both" } ] }, { "code_information": [ { "code": "27400096", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0499", "type": "HCPCS" } ], "description": "Hc Pocket Controler Consolidated Bag", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 826.26, "gross_charge": 1271.17, "setting": "both" } ] }, { "code_information": [ { "code": "27400097", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0498", "type": "HCPCS" } ], "description": "Hc Holster Vest Small", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 817.28, "gross_charge": 1257.35, "setting": "both" } ] }, { "code_information": [ { "code": "27400098", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0479", "type": "HCPCS" } ], "description": "Hc Power Module", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 16547.86, "gross_charge": 25458.25, "setting": "both" } ] }, { "code_information": [ { "code": "27400099", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0495", "type": "HCPCS" } ], "description": "Hc Battery Charger", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14893.34, "gross_charge": 22912.83, "setting": "both" } ] }, { "code_information": [ { "code": "27400100", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0508", "type": "HCPCS" } ], "description": "Hc Pocket Controller Wear Access Kit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 351.4, "gross_charge": 540.62, "setting": "both" } ] }, { "code_information": [ { "code": "27400101", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0508", "type": "HCPCS" } ], "description": "Hc Power Module Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3340.99, "gross_charge": 5139.98, "setting": "both" } ] }, { "code_information": [ { "code": "27400102", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0508", "type": "HCPCS" } ], "description": "Hc Power Module Ac Cord", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 90.51, "gross_charge": 139.25, "setting": "both" } ] }, { "code_information": [ { "code": "27400103", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0478", "type": "HCPCS" } ], "description": "Hc Power Module Dc Input Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 601.65, "gross_charge": 925.61, "setting": "both" } ] }, { "code_information": [ { "code": "27400104", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0496", "type": "HCPCS" } ], "description": "Hc 12 Volt Sla Battery Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 155.07, "gross_charge": 238.57, "setting": "both" } ] }, { "code_information": [ { "code": "27400106", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0486", "type": "HCPCS" } ], "description": "Hc Display Module To Power Module", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 852.55, "gross_charge": 1311.62, "setting": "both" } ] }, { "code_information": [ { "code": "27400228", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3980", "type": "HCPCS" } ], "description": "Hc L3980 Humeral Fx Brace W/Adj No Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 792.65, "gross_charge": 1219.46, "setting": "both" } ] }, { "code_information": [ { "code": "27400231", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3995", "type": "HCPCS" } ], "description": "Hc L3995 Upper Extremity Fx Sock", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.2, "gross_charge": 124.92, "setting": "both" } ] }, { "code_information": [ { "code": "27400256", "type": "CDM" }, { "code": "290", "type": "RC" }, { "code": "E0860", "type": "HCPCS" } ], "description": "Hc Cervical Traction Over Door", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.24, "gross_charge": 88.06, "setting": "both" } ] }, { "code_information": [ { "code": "27400278", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L2999", "type": "HCPCS" } ], "description": "Hc Afo Footplate Dynamic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 426.61, "gross_charge": 656.32, "setting": "both" } ] }, { "code_information": [ { "code": "27400279", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L4397", "type": "HCPCS" } ], "description": "Hc Afo Prefab Ots", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.59, "gross_charge": 65.53, "setting": "both" } ] }, { "code_information": [ { "code": "27400280", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0498", "type": "HCPCS" } ], "description": "Hc Hw Waist Pack", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1050.21, "gross_charge": 1615.71, "setting": "both" } ] }, { "code_information": [ { "code": "27400286", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0481", "type": "HCPCS" } ], "description": "Hc Hm3 Lvad Controller W Ebb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11463.34, "gross_charge": 17635.91, "setting": "both" } ] }, { "code_information": [ { "code": "27400287", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0508", "type": "HCPCS" } ], "description": "Hc Hm3 Lvad Modular Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10239.26, "gross_charge": 15752.7, "setting": "both" } ] }, { "code_information": [ { "code": "27400291", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "Q0481", "type": "HCPCS" } ], "description": "Hc Heartmate Ii System Controller Epc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10796.31, "gross_charge": 16609.71, "setting": "both" } ] }, { "code_information": [ { "code": "27400330", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3923", "type": "HCPCS" } ], "description": "Hc Hand Finger W/O Joints W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.44, "gross_charge": 200.68, "setting": "both" } ] }, { "code_information": [ { "code": "27400331", "type": "CDM" }, { "code": "274", "type": "RC" }, { "code": "L3915", "type": "HCPCS" } ], "description": "Hc Who Nontorsion Jnts W/Adj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 711.46, "gross_charge": 1094.55, "setting": "both" } ] }, { "code_information": [ { "code": "27500002", "type": "CDM" }, { "code": "275", "type": "RC" }, { "code": "C1785", "type": "HCPCS" } ], "description": "Hc Pacemaker Dual Chamber Rate Responsive", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6114.73, "gross_charge": 9407.28, "setting": "both" } ] }, { "code_information": [ { "code": "27500003", "type": "CDM" }, { "code": "275", "type": "RC" }, { "code": "C1786", "type": "HCPCS" } ], "description": "Hc Pacemaker Single Chamber Rate Responsive", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 20783.35, "gross_charge": 31974.38, "setting": "both" } ] }, { "code_information": [ { "code": "27500004", "type": "CDM" }, { "code": "275", "type": "RC" }, { "code": "C1898", "type": "HCPCS" } ], "description": "Hc Lead Pacemaker Not Transvenous Vdd Sgl Pass", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 604.55, "gross_charge": 930.08, "setting": "both" } ] }, { "code_information": [ { "code": "27500006", "type": "CDM" }, { "code": "275", "type": "RC" }, { "code": "C1900", "type": "HCPCS" } ], "description": "Hc Lead Coronary Venous System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2880.4, "gross_charge": 4431.39, "setting": "both" } ] }, { "code_information": [ { "code": "27500009", "type": "CDM" }, { "code": "275", "type": "RC" }, { "code": "C2621", "type": "HCPCS" } ], "description": "Hc Pacemaker Other Than Sgl Or Dual Chamber", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8893.61, "gross_charge": 13682.47, "setting": "both" } ] }, { "code_information": [ { "code": "27800002", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4100", "type": "HCPCS" } ], "description": "Hc Skin Substitute Not Otherwise Specified", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17.21, "gross_charge": 26.48, "setting": "both" } ] }, { "code_information": [ { "code": "27800003", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4101", "type": "HCPCS" } ], "description": "Hc Apligraf Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 61.77, "gross_charge": 95.03, "setting": "both" } ] }, { "code_information": [ { "code": "27800005", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4104", "type": "HCPCS" } ], "description": "Hc Bilayer Matrix Wound Drsg Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 63.43, "gross_charge": 97.59, "setting": "both" } ] }, { "code_information": [ { "code": "27800006", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "Q4105", "type": "HCPCS" } ], "description": "Hc Dermal Regeneration Template Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 150.6, "gross_charge": 231.69, "setting": "both" } ] }, { "code_information": [ { "code": "27800008", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4107", "type": "HCPCS" } ], "description": "Hc Graft Jacket Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 277.15, "gross_charge": 426.39, "setting": "both" } ] }, { "code_information": [ { "code": "27800009", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4108", "type": "HCPCS" } ], "description": "Hc Integra Matrix Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 169.53, "gross_charge": 260.81, "setting": "both" } ] }, { "code_information": [ { "code": "27800014", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4116", "type": "HCPCS" } ], "description": "Hc Alloderm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 83.23, "gross_charge": 128.05, "setting": "both" } ] }, { "code_information": [ { "code": "27800015", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4118", "type": "HCPCS" } ], "description": "Hc Matristem Micromatrix Per Mg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.05, "gross_charge": 7.77, "setting": "both" } ] }, { "code_information": [ { "code": "27800018", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4130", "type": "HCPCS" } ], "description": "Hc Strattice Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 68.43, "gross_charge": 105.27, "setting": "both" } ] }, { "code_information": [ { "code": "27800032", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "A4648", "type": "HCPCS" } ], "description": "Hc Clip Marker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 203.65, "gross_charge": 313.31, "setting": "both" } ] }, { "code_information": [ { "code": "27800045", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2616", "type": "HCPCS" } ], "description": "Hc Yttrium-90 Nonstranded Per Source", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37835.67, "gross_charge": 58208.72, "setting": "both" } ] }, { "code_information": [ { "code": "27800062", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2639", "type": "HCPCS" } ], "description": "Hc Brachytherapy Source I 125 Nonstranded Per Source", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.61, "gross_charge": 53.24, "setting": "both" } ] }, { "code_information": [ { "code": "27800063", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1717", "type": "HCPCS" } ], "description": "Hc Rt Isotope Ir-192", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 364.29, "gross_charge": 560.45, "setting": "both" } ] }, { "code_information": [ { "code": "27800065", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1765", "type": "HCPCS" } ], "description": "Hc Seprafilm Adhesion Barrier", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 637.58, "gross_charge": 980.9, "setting": "both" } ] }, { "code_information": [ { "code": "27800068", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3166.42, "gross_charge": 4871.42, "setting": "both" } ] }, { "code_information": [ { "code": "27800072", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "description": "Hc Anchor Screw Bone Or Soft Tissue To Bone", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 858.48, "gross_charge": 1320.74, "setting": "both" } ] }, { "code_information": [ { "code": "27800073", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1721", "type": "HCPCS" } ], "description": "Hc Icd Dual Chamber", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 20891.74, "gross_charge": 32141.14, "setting": "both" } ] }, { "code_information": [ { "code": "27800074", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1722", "type": "HCPCS" } ], "description": "Hc Icd Single Chamber", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30499.15, "gross_charge": 46921.77, "setting": "both" } ] }, { "code_information": [ { "code": "27800075", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1760", "type": "HCPCS" } ], "description": "Hc Closure Device Vascular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 415.25, "gross_charge": 638.85, "setting": "both" } ] }, { "code_information": [ { "code": "27800076", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1762", "type": "HCPCS" } ], "description": "Hc Connective Tissue Human", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3836.57, "gross_charge": 5902.41, "setting": "both" } ] }, { "code_information": [ { "code": "27800077", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1760", "type": "HCPCS" } ], "description": "Hc Vasc Closure Device Angioseal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 341.42, "gross_charge": 525.26, "setting": "both" } ] }, { "code_information": [ { "code": "27800078", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1763", "type": "HCPCS" } ], "description": "Hc Connective Tissue Non Human", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1945.68, "gross_charge": 2993.36, "setting": "both" } ] }, { "code_information": [ { "code": "27800079", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1764", "type": "HCPCS" } ], "description": "Hc Event Recorder Cardiac", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8483.87, "gross_charge": 13052.11, "setting": "both" } ] }, { "code_information": [ { "code": "27800080", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1765", "type": "HCPCS" } ], "description": "Hc Adhesion Barrier", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 764.65, "gross_charge": 1176.39, "setting": "both" } ] }, { "code_information": [ { "code": "27800081", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1767", "type": "HCPCS" } ], "description": "Hc Generator Neurostim Nonrechargeable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30770.74, "gross_charge": 47339.6, "setting": "both" } ] }, { "code_information": [ { "code": "27800082", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1768", "type": "HCPCS" } ], "description": "Hc Graft Vascular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1628.11, "gross_charge": 2504.78, "setting": "both" } ] }, { "code_information": [ { "code": "27800083", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1771", "type": "HCPCS" } ], "description": "Hc Sling Incontinence Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2830.48, "gross_charge": 4354.59, "setting": "both" } ] }, { "code_information": [ { "code": "27800084", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1772", "type": "HCPCS" } ], "description": "Hc Infusion Pump Programmable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 22538.68, "gross_charge": 34674.89, "setting": "both" } ] }, { "code_information": [ { "code": "27800085", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1776", "type": "HCPCS" } ], "description": "Hc Joint Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2555.95, "gross_charge": 3932.23, "setting": "both" } ] }, { "code_information": [ { "code": "27800086", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1777", "type": "HCPCS" } ], "description": "Hc Lead Icd Single Coil", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4772.98, "gross_charge": 7343.05, "setting": "both" } ] }, { "code_information": [ { "code": "27800088", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1778", "type": "HCPCS" } ], "description": "Hc Lead Neurostimulator Implantable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5553.44, "gross_charge": 8543.76, "setting": "both" } ] }, { "code_information": [ { "code": "27800089", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1781", "type": "HCPCS" } ], "description": "Hc Mesh Implantable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1148.98, "gross_charge": 1767.66, "setting": "both" } ] }, { "code_information": [ { "code": "27800090", "type": "CDM" }, { "code": "271", "type": "RC" }, { "code": "C1787", "type": "HCPCS" } ], "description": "Hc Patient Programmer Neurostimulator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2560.14, "gross_charge": 3938.67, "setting": "both" } ] }, { "code_information": [ { "code": "27800091", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1788", "type": "HCPCS" } ], "description": "Hc Port Indwelling", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 896.84, "gross_charge": 1379.75, "setting": "both" } ] }, { "code_information": [ { "code": "27800092", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1789", "type": "HCPCS" } ], "description": "Hc Prosthesis Breast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2751.48, "gross_charge": 4233.05, "setting": "both" } ] }, { "code_information": [ { "code": "27800093", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1813", "type": "HCPCS" } ], "description": "Hc Prosthesis Penile Inflatable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10235.42, "gross_charge": 15746.8, "setting": "both" } ] }, { "code_information": [ { "code": "27800094", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1815", "type": "HCPCS" } ], "description": "Hc Prosthesis Urinary Sphincter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11018.46, "gross_charge": 16951.48, "setting": "both" } ] }, { "code_information": [ { "code": "27800095", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1817", "type": "HCPCS" } ], "description": "Hc Implant Septal Occlusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 15365.68, "gross_charge": 23639.5, "setting": "both" } ] }, { "code_information": [ { "code": "27800096", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1820", "type": "HCPCS" } ], "description": "Hc Generator Neurostim W Charging System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 25995.57, "gross_charge": 39993.18, "setting": "both" } ] }, { "code_information": [ { "code": "27800097", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Stent Coated W Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2087.63, "gross_charge": 3211.74, "setting": "both" } ] }, { "code_information": [ { "code": "27800099", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1876", "type": "HCPCS" } ], "description": "Hc Stent Non Coated W Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7787.21, "gross_charge": 11980.32, "setting": "both" } ] }, { "code_information": [ { "code": "27800100", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1877", "type": "HCPCS" } ], "description": "Hc Stent Non Coated Wo Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1677.15, "gross_charge": 2580.23, "setting": "both" } ] }, { "code_information": [ { "code": "27800101", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1878", "type": "HCPCS" } ], "description": "Hc Material Vocal Cord Medlztn Synth", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1357.69, "gross_charge": 2088.76, "setting": "both" } ] }, { "code_information": [ { "code": "27800103", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1880", "type": "HCPCS" } ], "description": "Hc Filter Vena Cava", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1861.69, "gross_charge": 2864.14, "setting": "both" } ] }, { "code_information": [ { "code": "27800104", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1881", "type": "HCPCS" } ], "description": "Hc Dialysis Access System Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 220.95, "gross_charge": 339.93, "setting": "both" } ] }, { "code_information": [ { "code": "27800105", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1882", "type": "HCPCS" } ], "description": "Hc Icd Other Than Single Or Dual Chamber", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26029.41, "gross_charge": 40045.24, "setting": "both" } ] }, { "code_information": [ { "code": "27800106", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1883", "type": "HCPCS" } ], "description": "Hc Extension Pacing Or Neurostim Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 885.52, "gross_charge": 1362.34, "setting": "both" } ] }, { "code_information": [ { "code": "27800107", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C1884", "type": "HCPCS" } ], "description": "Hc Embolization Protection System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2869.94, "gross_charge": 4415.29, "setting": "both" } ] }, { "code_information": [ { "code": "27800108", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1895", "type": "HCPCS" } ], "description": "Hc Lead Icd Dual Coil", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8597.15, "gross_charge": 13226.38, "setting": "both" } ] }, { "code_information": [ { "code": "27800109", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1896", "type": "HCPCS" } ], "description": "Noncdm Charge Record Medical Supplies", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9175.83, "gross_charge": 14116.66, "setting": "both" } ] }, { "code_information": [ { "code": "27800110", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1897", "type": "HCPCS" } ], "description": "Hc Lead Neurostim Test Kit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1412.11, "gross_charge": 2172.48, "setting": "both" } ] }, { "code_information": [ { "code": "27800112", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2617", "type": "HCPCS" } ], "description": "Hc Stent Non Coronary Temp Wo Deliv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 252.97, "gross_charge": 389.19, "setting": "both" } ] }, { "code_information": [ { "code": "27800113", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2622", "type": "HCPCS" } ], "description": "Hc Prosthesis Penile Non Inflatable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19920.67, "gross_charge": 30647.19, "setting": "both" } ] }, { "code_information": [ { "code": "27800114", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2625", "type": "HCPCS" } ], "description": "Hc Stent Non Coronary Temp W Deliv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 455.47, "gross_charge": 700.73, "setting": "both" } ] }, { "code_information": [ { "code": "27800116", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2638", "type": "HCPCS" } ], "description": "Hc Brachytherapy Source I 125 Stranded Per Source", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.58, "gross_charge": 77.82, "setting": "both" } ] }, { "code_information": [ { "code": "27800118", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9250", "type": "HCPCS" } ], "description": "Hc Sealant Fibrin Human Plasma (Artiss) Per 2Ml", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 461.99, "gross_charge": 710.76, "setting": "both" } ] }, { "code_information": [ { "code": "27800119", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C9352", "type": "HCPCS" } ], "description": "Hc Nerve Guide Per Cm Length", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1566.54, "gross_charge": 2410.06, "setting": "both" } ] }, { "code_information": [ { "code": "27800120", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C9353", "type": "HCPCS" } ], "description": "Hc Neurowrap Per Cm Length", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1126.48, "gross_charge": 1733.04, "setting": "both" } ] }, { "code_information": [ { "code": "27800121", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C9356", "type": "HCPCS" } ], "description": "Hc Tenoglide Tendon Protector Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 58.29, "gross_charge": 89.67, "setting": "both" } ] }, { "code_information": [ { "code": "27800126", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "L8606", "type": "HCPCS" } ], "description": "Hc Agent Bulking Synth Urin Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2098.54, "gross_charge": 3228.52, "setting": "both" } ] }, { "code_information": [ { "code": "27800127", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "L8614", "type": "HCPCS" } ], "description": "Hc Cochlear W All Int And Ext Components", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28091.95, "gross_charge": 43218.38, "setting": "both" } ] }, { "code_information": [ { "code": "27800128", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "L8690", "type": "HCPCS" } ], "description": "Hc Aud Osseointegrated Device W All Int And Ext Comps", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14039.06, "gross_charge": 21598.56, "setting": "both" } ] }, { "code_information": [ { "code": "27800129", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4100", "type": "HCPCS" } ], "description": "Hc Amniotic Membrane For Surg Recon Per Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1030.87, "gross_charge": 1585.95, "setting": "both" } ] }, { "code_information": [ { "code": "27800136", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1081.5, "gross_charge": 1663.84, "setting": "both" } ] }, { "code_information": [ { "code": "27800145", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Lead Myocardial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 846.34, "gross_charge": 1302.06, "setting": "both" } ] }, { "code_information": [ { "code": "27800148", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1287.14, "gross_charge": 1980.22, "setting": "both" } ] }, { "code_information": [ { "code": "27800149", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1715.75, "gross_charge": 2639.61, "setting": "both" } ] }, { "code_information": [ { "code": "27800150", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 4", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2145.68, "gross_charge": 3301.05, "setting": "both" } ] }, { "code_information": [ { "code": "27800151", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2574.29, "gross_charge": 3960.45, "setting": "both" } ] }, { "code_information": [ { "code": "27800152", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 6", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3004.22, "gross_charge": 4621.88, "setting": "both" } ] }, { "code_information": [ { "code": "27800153", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 7", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3354.16, "gross_charge": 5160.24, "setting": "both" } ] }, { "code_information": [ { "code": "27800154", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 8", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3760.47, "gross_charge": 5785.34, "setting": "both" } ] }, { "code_information": [ { "code": "27800155", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 9", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4202.39, "gross_charge": 6465.21, "setting": "both" } ] }, { "code_information": [ { "code": "27800156", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 10", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5025.22, "gross_charge": 7731.1, "setting": "both" } ] }, { "code_information": [ { "code": "27800157", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 11", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6007.12, "gross_charge": 9241.72, "setting": "both" } ] }, { "code_information": [ { "code": "27800158", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 12", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6723.57, "gross_charge": 10343.95, "setting": "both" } ] }, { "code_information": [ { "code": "27800159", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 13", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7609.39, "gross_charge": 11706.76, "setting": "both" } ] }, { "code_information": [ { "code": "27800160", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 14", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8365.49, "gross_charge": 12869.98, "setting": "both" } ] }, { "code_information": [ { "code": "27800161", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 15", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9221.65, "gross_charge": 14187.16, "setting": "both" } ] }, { "code_information": [ { "code": "27800162", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 16", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9994.34, "gross_charge": 15375.91, "setting": "both" } ] }, { "code_information": [ { "code": "27800163", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 17", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11157.03, "gross_charge": 17164.66, "setting": "both" } ] }, { "code_information": [ { "code": "27800164", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 18", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12015.57, "gross_charge": 18485.49, "setting": "both" } ] }, { "code_information": [ { "code": "27800165", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 19", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12492.76, "gross_charge": 19219.63, "setting": "both" } ] }, { "code_information": [ { "code": "27800166", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 20", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13732.65, "gross_charge": 21127.15, "setting": "both" } ] }, { "code_information": [ { "code": "27800167", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 21", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14266.58, "gross_charge": 21948.58, "setting": "both" } ] }, { "code_information": [ { "code": "27800168", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 22", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15448.4, "gross_charge": 23766.77, "setting": "both" } ] }, { "code_information": [ { "code": "27800169", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 23", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 15971.09, "gross_charge": 24570.91, "setting": "both" } ] }, { "code_information": [ { "code": "27800170", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 24", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 16657.01, "gross_charge": 25626.17, "setting": "both" } ] }, { "code_information": [ { "code": "27800171", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Implant Impella Device 3.5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42359.97, "gross_charge": 65169.19, "setting": "both" } ] }, { "code_information": [ { "code": "27800172", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Pipeline Embolization L8699", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26507.08, "gross_charge": 40780.13, "setting": "both" } ] }, { "code_information": [ { "code": "27800181", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4128", "type": "HCPCS" } ], "description": "Hc Flex Hd Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 61.32, "gross_charge": 94.34, "setting": "both" } ] }, { "code_information": [ { "code": "27800186", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C9359", "type": "HCPCS" } ], "description": "Hc Bone Filler Putty Per .5Cc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3691.72, "gross_charge": 5679.57, "setting": "both" } ] }, { "code_information": [ { "code": "27800198", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1897", "type": "HCPCS" } ], "description": "Hc Lead Neurostim Multi Lead Trialing Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 361.39, "gross_charge": 555.98, "setting": "both" } ] }, { "code_information": [ { "code": "27800203", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Aortic Homograft Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33023.85, "gross_charge": 50805.92, "setting": "both" } ] }, { "code_information": [ { "code": "27800206", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1822", "type": "HCPCS" } ], "description": "Hc Gen Neurostim Hi Freq Recharg Batt And Charg Sys", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 15888.15, "gross_charge": 24443.31, "setting": "both" } ] }, { "code_information": [ { "code": "27800208", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "C2623", "type": "HCPCS" } ], "description": "Hc Catheter Ta Drug-Coated Non-Laser", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3827.08, "gross_charge": 5887.81, "setting": "both" } ] }, { "code_information": [ { "code": "27800211", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Prosthetic Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 27633.38, "gross_charge": 42512.9, "setting": "both" } ] }, { "code_information": [ { "code": "27800212", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Implant Not Otherwise Classifed", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5073.18, "gross_charge": 7804.89, "setting": "both" } ] }, { "code_information": [ { "code": "27800213", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Impella Right Side", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31973.63, "gross_charge": 49190.2, "setting": "both" } ] }, { "code_information": [ { "code": "27800214", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Impella Purge Cassette", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 413.97, "gross_charge": 636.87, "setting": "both" } ] }, { "code_information": [ { "code": "27800217", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2624", "type": "HCPCS" } ], "description": "Hc Wireless Pressure Sensor Incl All Components", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42927.01, "gross_charge": 66041.55, "setting": "both" } ] }, { "code_information": [ { "code": "27800218", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Hm3 Lvad Implant Kit W Controller", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 206693.21, "gross_charge": 317989.55, "setting": "both" } ] }, { "code_information": [ { "code": "27800219", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 25", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17488.93, "gross_charge": 26906.04, "setting": "both" } ] }, { "code_information": [ { "code": "27800220", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 26", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18880.56, "gross_charge": 29047.02, "setting": "both" } ] }, { "code_information": [ { "code": "27800221", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 27", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19737.77, "gross_charge": 30365.8, "setting": "both" } ] }, { "code_information": [ { "code": "27800222", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 28", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20594.98, "gross_charge": 31684.59, "setting": "both" } ] }, { "code_information": [ { "code": "27800223", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 29", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21452.85, "gross_charge": 33004.39, "setting": "both" } ] }, { "code_information": [ { "code": "27800224", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 30", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22310.73, "gross_charge": 34324.2, "setting": "both" } ] }, { "code_information": [ { "code": "27800225", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 31", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23168.61, "gross_charge": 35644.01, "setting": "both" } ] }, { "code_information": [ { "code": "27800226", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 32", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24025.81, "gross_charge": 36962.79, "setting": "both" } ] }, { "code_information": [ { "code": "27800227", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 33", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24884.35, "gross_charge": 38283.62, "setting": "both" } ] }, { "code_information": [ { "code": "27800228", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 34", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25741.56, "gross_charge": 39602.4, "setting": "both" } ] }, { "code_information": [ { "code": "27800229", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "A4648", "type": "HCPCS" } ], "description": "Hc Tissue Marker Implantable Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 230.97, "gross_charge": 355.34, "setting": "both" } ] }, { "code_information": [ { "code": "27800232", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1823", "type": "HCPCS" } ], "description": "Hc Generator Neurostim Non-Rchge With Sensing&Stim Leads", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 33942.28, "gross_charge": 52218.9, "setting": "both" } ] }, { "code_information": [ { "code": "27800234", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 35", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26599.44, "gross_charge": 40922.21, "setting": "both" } ] }, { "code_information": [ { "code": "27800235", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 36", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27457.31, "gross_charge": 42242.02, "setting": "both" } ] }, { "code_information": [ { "code": "27800236", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 37", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 28315.19, "gross_charge": 43561.83, "setting": "both" } ] }, { "code_information": [ { "code": "27800238", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Perfusion Tavr Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69276.2, "gross_charge": 106578.77, "setting": "both" } ] }, { "code_information": [ { "code": "27800239", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1819", "type": "HCPCS" } ], "description": "Hc Surgical Tissue Localization Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 59.07, "gross_charge": 90.88, "setting": "both" } ] }, { "code_information": [ { "code": "27800242", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1776", "type": "HCPCS" } ], "description": "Hc Hud Joint Implant C1776", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2465.14, "gross_charge": 3792.53, "setting": "both" } ] }, { "code_information": [ { "code": "27800246", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Hud Stent Coated W Del Sys C1874", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2220.67, "gross_charge": 3416.41, "setting": "both" } ] }, { "code_information": [ { "code": "27800247", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1876", "type": "HCPCS" } ], "description": "Hc Hud Stent Non Coated W Del Sys C1876", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5835.64, "gross_charge": 8977.9, "setting": "both" } ] }, { "code_information": [ { "code": "27800250", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "description": "Hc K-Wire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 65.05, "gross_charge": 100.08, "setting": "both" } ] }, { "code_information": [ { "code": "27800252", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1734", "type": "HCPCS" } ], "description": "Hc Augment Bone Matrix", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4574.99, "gross_charge": 7038.45, "setting": "both" } ] }, { "code_information": [ { "code": "27800253", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 38", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29172.4, "gross_charge": 44880.61, "setting": "both" } ] }, { "code_information": [ { "code": "27800254", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 39", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 30030.94, "gross_charge": 46201.44, "setting": "both" } ] }, { "code_information": [ { "code": "27800255", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 40", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30240.41, "gross_charge": 46523.71, "setting": "both" } ] }, { "code_information": [ { "code": "27800256", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 41", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31745.36, "gross_charge": 48839.01, "setting": "both" } ] }, { "code_information": [ { "code": "27800257", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Heart Valve 42", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32603.9, "gross_charge": 50159.84, "setting": "both" } ] }, { "code_information": [ { "code": "27800258", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1821", "type": "HCPCS" } ], "description": "Hc Interspinous Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10255.29, "gross_charge": 15777.37, "setting": "both" } ] }, { "code_information": [ { "code": "27800261", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1982", "type": "HCPCS" } ], "description": "Hc Catheter Pressure Gen W One Way Valve Occlusive", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 15473.69, "gross_charge": 23805.68, "setting": "both" } ] }, { "code_information": [ { "code": "27800263", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2613", "type": "HCPCS" } ], "description": "Hc Lung Biopsy Plug With Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 698.82, "gross_charge": 1075.1, "setting": "both" } ] }, { "code_information": [ { "code": "27800264", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "L8613", "type": "HCPCS" } ], "description": "Hc Ossicula Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 683.77, "gross_charge": 1051.95, "setting": "both" } ] }, { "code_information": [ { "code": "27800265", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1052", "type": "HCPCS" } ], "description": "Hc Hemospray Topical Gi Hemostatic Agent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1676.64, "gross_charge": 2579.44, "setting": "both" } ] }, { "code_information": [ { "code": "27800267", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1062", "type": "HCPCS" } ], "description": "Hc Intravertebral Fx Aug Implant - Stryker Spinejack", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8315.86, "gross_charge": 12793.63, "setting": "both" } ] }, { "code_information": [ { "code": "27800268", "type": "CDM" }, { "code": "278", "type": "RC" } ], "description": "Hc Implant Impella Device 5.5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 85290.31, "gross_charge": 131215.86, "setting": "both" } ] }, { "code_information": [ { "code": "27800269", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1761", "type": "HCPCS" } ], "description": "Hc Cath Trans Intra Litho Coro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9384.04, "gross_charge": 14436.99, "setting": "both" } ] }, { "code_information": [ { "code": "27800270", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2616", "type": "HCPCS" } ], "description": "Noncdm Charge Record Medical Supplies", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 35439.74, "gross_charge": 54522.68, "setting": "both" } ] }, { "code_information": [ { "code": "27800272", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1778", "type": "HCPCS" } ], "description": "Hc Kit Sprint Conversion System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10444.24, "gross_charge": 16068.06, "setting": "both" } ] }, { "code_information": [ { "code": "27800273", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1778", "type": "HCPCS" } ], "description": "Hc Kit Sprint Pns Endura Single Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10289.84, "gross_charge": 15830.52, "setting": "both" } ] }, { "code_information": [ { "code": "27800274", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1778", "type": "HCPCS" } ], "description": "Hc Kit Sprint Pns Extensa Dual Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16625.73, "gross_charge": 25578.05, "setting": "both" } ] }, { "code_information": [ { "code": "27800275", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1825", "type": "HCPCS" } ], "description": "Hc Generator Barostim Implantable Device, Non-Rechargeable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 39832.27, "gross_charge": 61280.42, "setting": "both" } ] }, { "code_information": [ { "code": "27800276", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1824", "type": "HCPCS" } ], "description": "Hc Cardiac Contractility Modulation Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 51911.73, "gross_charge": 79864.2, "setting": "both" } ] }, { "code_information": [ { "code": "27800278", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "description": "Hc Synthetic Bone Void Filler", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10675.05, "gross_charge": 16423.16, "setting": "both" } ] }, { "code_information": [ { "code": "27800279", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1605", "type": "HCPCS" } ], "description": "Noncdm Charge Record Medical Supplies", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12512.06, "gross_charge": 19249.32, "setting": "both" } ] }, { "code_information": [ { "code": "27800280", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C1713", "type": "HCPCS" } ], "description": "Hc Ifuse Bedrock Granite Implant System Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6668.66, "gross_charge": 10259.48, "setting": "both" } ] }, { "code_information": [ { "code": "30000001", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "36415", "type": "HCPCS" } ], "description": "Hc Venipuncture", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.0, "gross_charge": 20.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000002", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "36416", "type": "HCPCS" } ], "description": "Hc Collection Capillary Blood Specimen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.0, "gross_charge": 20.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000003", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86890", "type": "HCPCS" } ], "description": "Hc Blood Processing Fee Autologous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.1, "gross_charge": 214.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000004", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86891", "type": "HCPCS" } ], "description": "Hc Blood Salvage Autologous Intra Op", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6072.95, "gross_charge": 9343.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000005", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86900", "type": "HCPCS" } ], "description": "Hc Blood Typing Abo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 86.45, "gross_charge": 133.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000006", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86901", "type": "HCPCS" } ], "description": "Hc Blood Typing Rh D", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26.0, "gross_charge": 40.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000007", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86902", "type": "HCPCS" } ], "description": "Hc Rbc Antigen Scr Reagent Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 323.7, "gross_charge": 498.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000008", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86904", "type": "HCPCS" } ], "description": "Hc Screen Preselected Unit Per Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 447.2, "gross_charge": 688.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000009", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86905", "type": "HCPCS" } ], "description": "Hc Rbc Antigen Typing Non Abo Rh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 273.65, "gross_charge": 421.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000010", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86906", "type": "HCPCS" } ], "description": "Hc Rh Phenotype", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 495.3, "gross_charge": 762.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000011", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86920", "type": "HCPCS" } ], "description": "Hc Crossmatch Immediate Spin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.95, "gross_charge": 223.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000012", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86921", "type": "HCPCS" } ], "description": "Hc Incubation Of Crossmatch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000013", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86922", "type": "HCPCS" } ], "description": "Hc Agt Phase Of Crossmatch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 113.1, "gross_charge": 174.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000014", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86923", "type": "HCPCS" } ], "description": "Hc Crossmatch Electronic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000017", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86965", "type": "HCPCS" } ], "description": "Hc Blood Product Pooling", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 193.05, "gross_charge": 297.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000018", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86970", "type": "HCPCS" } ], "description": "Hc Pretreatment Rbcs W Chemical Drug", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 260.0, "gross_charge": 400.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000019", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86971", "type": "HCPCS" } ], "description": "Hc Pretreatment With Enzymes Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 222.95, "gross_charge": 343.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000020", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86972", "type": "HCPCS" } ], "description": "Hc Reticulocyte Separation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 423.8, "gross_charge": 652.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000021", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86975", "type": "HCPCS" } ], "description": "Hc Incubation Of Serum W/Drugs Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 773.5, "gross_charge": 1190.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000022", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86976", "type": "HCPCS" } ], "description": "Hc Dilution Of Serum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 397.8, "gross_charge": 612.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000023", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86977", "type": "HCPCS" } ], "description": "Hc Inhibition Of Serum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 341.25, "gross_charge": 525.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000024", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86978", "type": "HCPCS" } ], "description": "Hc Differential Adsorption Serum Ea", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 711.75, "gross_charge": 1095.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000025", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86985", "type": "HCPCS" } ], "description": "Hc Split Blood Product Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 297.7, "gross_charge": 458.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000026", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "88720", "type": "HCPCS" } ], "description": "Hc Bilirubin Total Transcutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 299.65, "gross_charge": 461.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000027", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "89050", "type": "HCPCS" } ], "description": "Hc Cell Count Body Fluid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 109.85, "gross_charge": 169.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000030", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "89051", "type": "HCPCS" } ], "description": "Hc Cell Count W Diff Body Fluid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 465.4, "gross_charge": 716.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000036", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "89060", "type": "HCPCS" } ], "description": "Hc Crystal Id Tissue Or Fluid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 159.25, "gross_charge": 245.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000037", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "89125", "type": "HCPCS" } ], "description": "Hc Fat Stain Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37.7, "gross_charge": 58.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000039", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "89190", "type": "HCPCS" } ], "description": "Hc Smear Nasal Eosinophils", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 162.5, "gross_charge": 250.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000040", "type": "CDM" }, { "code": "300", 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Standard", "billing_class": "facility", "discounted_cash": 565.5, "gross_charge": 870.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000249", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81373", "type": "HCPCS" } ], "description": "Hc Recipient Hla I Typing 1 Locus Lr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 276.9, "gross_charge": 426.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000250", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81376", "type": "HCPCS" } ], "description": "Hc Recipient Hla Ii Typing 1 Locus Lr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 485.55, "gross_charge": 747.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000251", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81378", "type": 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"gross_charge": 960.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000254", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81382", "type": "HCPCS" } ], "description": "Hc Recipient Hla Class Ii Typing High Resolution One Locus Ea So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 643.5, "gross_charge": 990.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000255", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86900", "type": "HCPCS" } ], "description": "Hc Recipient Blood Typing Abo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.95, "gross_charge": 123.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000256", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "86901", "type": "HCPCS" } ], "description": "Hc Recipient Blood Typing Rh D", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26.0, "gross_charge": 40.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000257", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81254", "type": "HCPCS" } ], "description": "Hc Gjb6 Gene Analysis Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 861.9, "gross_charge": 1326.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000258", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0282U", "type": "HCPCS" } ], "description": "Hc Rbc Dna Gnotyp 12 Bld Grp Predict 44 Rbc Ag Phnt So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1123.2, "gross_charge": 1728.0, "setting": "both" } ] }, { "code_information": [ { 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Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000262", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81258", "type": "HCPCS" } ], "description": "Hc Hba1/Hba2 Gene Family Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000263", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81362", "type": "HCPCS" } ], "description": "Hc Hbb Gene Known Family Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000264", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81326", "type": 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{ "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1468.35, "gross_charge": 2259.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000270", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81319", "type": "HCPCS" } ], "description": "Hc Pms2 Gene Dup/Delet Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 437.45, "gross_charge": 673.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000271", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81319", "type": "HCPCS" } ], "description": "Hc Pms2 Gene Dup/Delet Variants Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1114.75, "gross_charge": 1715.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000272", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81374", "type": "HCPCS" } ], "description": "Hc Hla I Low Resolution One Antigen Equivalent, Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 419.25, "gross_charge": 645.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000273", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81229", "type": "HCPCS" } ], "description": "Hc Cytogen M Array Copy No And Snp Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5796.7, "gross_charge": 8918.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000274", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81401", "type": "HCPCS" } ], "description": "Hc Mopath Level 2 Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1661.4, "gross_charge": 2556.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000275", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81403", "type": "HCPCS" } ], "description": "Hc Mopath Level 4 Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1708.2, "gross_charge": 2628.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000276", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81443", "type": "HCPCS" } ], "description": "Hc Genetic Testing For Severe Inherited Conditions Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9636.9, "gross_charge": 14826.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000277", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81479", "type": "HCPCS" } ], "description": "Hc Mopath Unlisted Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3098.55, "gross_charge": 4767.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000278", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81174", "type": "HCPCS" } ], "description": "Hc Ar Gene Known Familial Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1136.2, "gross_charge": 1748.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000279", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81289", "type": "HCPCS" } ], "description": "Hc Fxn Gene Known Familial Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1136.2, "gross_charge": 1748.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000280", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81308", "type": "HCPCS" } ], "description": "Hc Palb2 Gene Known Familial Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1136.2, "gross_charge": 1748.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000283", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0364U", "type": "HCPCS" } ], "description": "Hc Clonoseq Assay Adaptive Biotechnologies So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4563.0, "gross_charge": 7020.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000284", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81321", "type": "HCPCS" } ], "description": "Hc Pten Full Gene Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3489.2, "gross_charge": 5368.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000285", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0355U", "type": "HCPCS" } ], "description": "Hc Apolipoprotein L1 (Apol1) Renal Risk Variant Genotyping, Quest Diagnostics So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 292.5, "gross_charge": 450.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000286", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81517", "type": "HCPCS" } ], "description": "Hc Liver Ds Alys 3 Bmrk Srm Alg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 260.65, "gross_charge": 401.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000287", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "83951", "type": "HCPCS" } ], "description": "Hc Des-Gamma-Carboxy Prothrombin S So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 390.0, "gross_charge": 600.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000288", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0346U", "type": "HCPCS" } ], "description": "Hc Amyloid Beta 42 Peptipe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1677.0, "gross_charge": 2580.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000289", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0503U", "type": "HCPCS" } ], "description": "Hc Precivityad2, P So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3393.0, "gross_charge": 5220.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000293", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0480U", "type": "HCPCS" } ], "description": "Hc Metagenomic Sequencing, Csf So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5850.0, "gross_charge": 9000.0, "setting": "both" } ] }, { "code_information": [ { "code": "30000294", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85046", "type": "HCPCS" } ], "description": "Hc Reticulocyte Profile, B So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.7, "gross_charge": 318.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100001", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80047", "type": "HCPCS" } ], "description": "Hc Basic Metabolic Panel Calcium Ionized", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.95, "gross_charge": 63.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100002", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80048", "type": "HCPCS" } ], "description": "Hc Basic Metabolic Panel Calcium Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 36.4, "gross_charge": 56.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100003", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80050", "type": "HCPCS" } ], "description": "Hc General Health Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 142.35, "gross_charge": 219.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100004", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80051", "type": "HCPCS" } ], "description": "Hc Electrolyte Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.9, "gross_charge": 46.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100005", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80053", "type": "HCPCS" } ], "description": "Hc Comprehensive Metabolic Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.1, "gross_charge": 74.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100006", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80055", "type": "HCPCS" } ], "description": "Hc Obstetric Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 196.3, "gross_charge": 302.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100007", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80061", "type": "HCPCS" } ], "description": "Hc Lipid Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 39.65, "gross_charge": 61.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100008", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80069", "type": "HCPCS" } ], "description": "Hc Renal Function Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.9, "gross_charge": 66.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100009", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80074", "type": "HCPCS" } ], "description": "Hc Hepatitis Panel Acute", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 284.7, "gross_charge": 438.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100010", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80076", "type": "HCPCS" } ], "description": "Hc Hepatic Function Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18.2, "gross_charge": 28.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100014", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80150", "type": "HCPCS" } ], "description": "Hc Amikacin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 71.5, "gross_charge": 110.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100017", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80156", "type": "HCPCS" } ], "description": "Hc Carbamazepine Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.25, "gross_charge": 85.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100018", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80157", "type": "HCPCS" } ], "description": "Hc Carbamazepine Free So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 421.85, "gross_charge": 649.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100019", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80158", "type": "HCPCS" } ], "description": "Hc Cyclosporine Level So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100021", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80162", "type": "HCPCS" } ], "description": "Hc Digoxin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 58.5, "gross_charge": 90.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100022", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80164", "type": "HCPCS" } ], "description": "Hc Valproic Acid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.9, "gross_charge": 66.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100024", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80168", "type": "HCPCS" } ], "description": "Hc Ethosuximide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 82.55, "gross_charge": 127.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100025", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80170", "type": "HCPCS" } ], "description": "Hc Gentamicin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100027", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80173", "type": "HCPCS" } ], "description": "Hc Haloperidol So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100029", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80176", "type": "HCPCS" } ], "description": "Hc Lidocaine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 152.1, "gross_charge": 234.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100030", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80178", "type": "HCPCS" } ], "description": "Hc Lithium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.3, "gross_charge": 82.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100033", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80185", "type": "HCPCS" } ], "description": "Hc Phenytoin Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.25, "gross_charge": 85.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100034", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80186", "type": "HCPCS" } ], "description": "Hc Phenytoin Free", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 100.1, "gross_charge": 154.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100035", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80188", "type": "HCPCS" } ], "description": "Hc Primidone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 111.15, "gross_charge": 171.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100036", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80192", "type": "HCPCS" } ], "description": "Hc Procainamide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 96.2, "gross_charge": 148.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100037", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80194", "type": "HCPCS" } ], "description": "Hc Quinidine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.2, "gross_charge": 128.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100038", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80195", "type": "HCPCS" } ], "description": "Hc Sirolimus So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26.65, "gross_charge": 41.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100039", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80329", "type": "HCPCS" } ], "description": "Hc Salicylate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 58.5, "gross_charge": 90.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100040", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80197", "type": "HCPCS" } ], "description": "Hc Tacrolimus So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100041", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80198", "type": "HCPCS" } ], "description": "Hc Theophylline", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 70.2, "gross_charge": 108.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100042", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80200", "type": "HCPCS" } ], "description": "Hc Tobramycin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 80.6, "gross_charge": 124.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100043", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80201", "type": "HCPCS" } ], "description": "Hc Topiramate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.95, "gross_charge": 103.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100044", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80202", "type": "HCPCS" } ], "description": "Hc Vancomycin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.2, "gross_charge": 88.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100046", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80400", "type": "HCPCS" } ], "description": "Hc Acth Stimulation Panel Adrenal Insufficiency", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 343.2, "gross_charge": 528.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100047", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "81050", "type": "HCPCS" } ], "description": "Hc Urine Volume Measurement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.1, "gross_charge": 54.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100048", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81200", "type": "HCPCS" } ], "description": "Hc Aspa Gene Analysis Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 336.7, "gross_charge": 518.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100051", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81208", "type": "HCPCS" } ], "description": "Hc Bcr Abl1 Other Breakpnt Qualitative Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 512.85, "gross_charge": 789.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100052", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81209", "type": "HCPCS" } ], "description": "Hc Bloom Syndrome Mutation Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 733.2, "gross_charge": 1128.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100053", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81210", "type": "HCPCS" } ], "description": "Hc Braf Gene Mut Anlys V600E Tumor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1929.2, "gross_charge": 2968.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100054", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81220", "type": "HCPCS" } ], "description": "Hc Cystic Fibrosis Mutation Panel So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 338.65, "gross_charge": 521.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100055", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "81221", "type": "HCPCS" } ], "description": "Hc Cftr Gene Known Mutation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100056", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81222", "type": "HCPCS" } ], "description": "Hc Cftr Gene Duplication Deletion Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 989.3, "gross_charge": 1522.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100057", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81225", "type": "HCPCS" } ], "description": "Hc Cyp2C19 Gene Analysis Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 877.5, "gross_charge": 1350.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100058", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81226", "type": "HCPCS" } ], "description": "Hc Cyp2D6 Gene Analysis Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 423.8, "gross_charge": 652.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100060", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81228", "type": "HCPCS" } ], "description": "Hc Cytogen Microarray Number So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3700.45, "gross_charge": 5693.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100061", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81240", "type": "HCPCS" } ], "description": "Hc Prothrombin G20210A Mutation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 137.15, "gross_charge": 211.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100062", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81241", "type": "HCPCS" } ], "description": "Hc Factor V Leiden (R506Q) Mutation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 137.15, "gross_charge": 211.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100063", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81242", "type": "HCPCS" } ], "description": "Hc Fanconi Anemia Mutation Analysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 733.2, "gross_charge": 1128.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100064", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81243", "type": "HCPCS" } ], "description": "Hc Fmr1 Gene Detection So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 438.75, "gross_charge": 675.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100065", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81244", "type": "HCPCS" } ], "description": "Hc Fmr1 Gene Characterization So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 533.65, "gross_charge": 821.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100066", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81245", "type": "HCPCS" } ], "description": "Hc Flt3 Mutation Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 835.9, "gross_charge": 1286.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100067", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81251", "type": "HCPCS" } ], "description": "Hc Gaucher Disease Mutation Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 612.95, "gross_charge": 943.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100068", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81255", "type": "HCPCS" } ], "description": "Hc Tay-Sachs Mutation Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 544.05, "gross_charge": 837.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100069", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81256", "type": "HCPCS" } ], "description": "Hc Hemochromatosis Hfe Gene Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 262.6, "gross_charge": 404.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100070", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81257", "type": "HCPCS" } ], "description": "Hc Hba1/Hba2 Alpha-Globin Gene Anlys Common Deletions/Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 630.5, "gross_charge": 970.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100071", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81260", "type": "HCPCS" } ], "description": "Hc Familial Dysautonomia Mutation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 733.2, "gross_charge": 1128.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100072", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81263", "type": "HCPCS" } ], "description": "Hc Igvh Mutation Analysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1034.15, "gross_charge": 1591.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100073", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81265", "type": "HCPCS" } ], "description": "Hc Str Markers Specimen Anlys So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 952.9, "gross_charge": 1466.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100074", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81270", "type": "HCPCS" } ], "description": "Hc Jak2 V617F Mutation Detection So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 438.75, "gross_charge": 675.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100075", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81275", "type": "HCPCS" } ], "description": "Hc Kras Gene 7 Mutation Panel Tumor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1946.1, "gross_charge": 2994.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100076", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81290", "type": "HCPCS" } ], "description": "Hc Mucolipidosis Iv Mutation Analys", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 763.75, "gross_charge": 1175.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100077", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81291", "type": "HCPCS" } ], "description": "Hc Mthfr Mutation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.3, "gross_charge": 222.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100078", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81292", "type": "HCPCS" } ], "description": "Hc Mlh1 Gene Full Seq So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1418.95, "gross_charge": 2183.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100079", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81293", "type": "HCPCS" } ], "description": "Hc Mlh1 Known Variants", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 351.0, "gross_charge": 540.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100081", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81295", "type": "HCPCS" } ], "description": "Hc Msh2 Gene Full Sequence Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1418.95, "gross_charge": 2183.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100082", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "81296", "type": "HCPCS" } ], "description": "Hc Msh2 Known Mutation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100084", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81298", "type": "HCPCS" } ], "description": "Hc Msh6 Mutation Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1378.65, "gross_charge": 2121.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100085", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "81299", "type": "HCPCS" } ], "description": "Hc Msh6 Known Mutation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100087", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81301", "type": "HCPCS" } ], "description": "Hc Microsatellite Instability Msi Tum So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1976.65, "gross_charge": 3041.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100089", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "81303", "type": "HCPCS" } ], "description": "Hc Mecp2 Gene Known Mutation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100091", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81310", "type": "HCPCS" } ], "description": "Hc Npm1 Gene", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 820.3, "gross_charge": 1262.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100092", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81315", "type": "HCPCS" } ], "description": "Hc Pml/Raralpha Common Breakpoints So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 910.0, "gross_charge": 1400.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100093", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81330", "type": "HCPCS" } ], "description": "Hc Niemann Pick Disease Type A And B", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 733.2, "gross_charge": 1128.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100094", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81331", "type": "HCPCS" } ], "description": "Hc Prader Willi Angelman Mol Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 678.6, "gross_charge": 1044.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100095", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81332", "type": "HCPCS" } ], "description": "Hc Serpina 1 Gene", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 163.8, "gross_charge": 252.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100096", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81340", "type": "HCPCS" } ], "description": "Hc Trb@ Gene Rearrange Amplify So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 222.95, "gross_charge": 343.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100098", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81342", "type": "HCPCS" } ], "description": "Hc Trb@ Gene Rearrangement Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 222.95, "gross_charge": 343.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100099", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "81350", "type": "HCPCS" } ], "description": "Hc Ugt1A1 Sequence Gene Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1714.7, "gross_charge": 2638.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100100", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81372", "type": "HCPCS" } ], "description": "Hc Hla Class I Typing Low Resolution Complete So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 349.7, "gross_charge": 538.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100101", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81375", "type": "HCPCS" } ], "description": "Hc Hla Class Ii Mol Typing Dis Assoc So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 222.95, "gross_charge": 343.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100102", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81376", "type": "HCPCS" } ], "description": "Hc Hla Ii Typing 1 Locus Lr Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 193.05, "gross_charge": 297.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100104", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81381", "type": "HCPCS" } ], "description": "Hc Hla Typing 1 Allele Hr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 306.8, "gross_charge": 472.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100105", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81383", "type": "HCPCS" } ], "description": "Hc Narcolepsy Associated Ag", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 136.5, "gross_charge": 210.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100108", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81404", "type": "HCPCS" } ], "description": "Hc Molecular Pathology Procedure Level 5 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1859.65, "gross_charge": 2861.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100110", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81408", "type": "HCPCS" } ], "description": "Hc Fbn1 Full Gene Sequence", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5243.55, "gross_charge": 8067.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100111", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81479", "type": "HCPCS" } ], "description": "Hc Unlisted Molecular Pathology Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1199.25, "gross_charge": 1845.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100114", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "81511", "type": "HCPCS" } ], "description": "Hc Fet Con Abn Afp4 Algorithm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 172.25, "gross_charge": 265.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100115", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80329", "type": "HCPCS" } ], "description": "Hc Analgesics Non-Opiod; 1 Or 2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 58.5, "gross_charge": 90.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100116", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82009", "type": "HCPCS" } ], "description": "Hc Ketone Bodies Serum Qualitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 52.65, "gross_charge": 81.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100117", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82010", "type": "HCPCS" } ], "description": "Hc Ketone Bodies Serum Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.1, "gross_charge": 114.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100118", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82013", "type": "HCPCS" } ], "description": "Hc Acetylcholinesterase So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 234.65, "gross_charge": 361.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100119", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82017", "type": "HCPCS" } ], "description": "Hc Acylcarnitines Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 126.75, "gross_charge": 195.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100120", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82024", "type": "HCPCS" } ], "description": "Hc Acth", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.05, "gross_charge": 117.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100121", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82030", "type": "HCPCS" } ], "description": "Hc Cyclic Amp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 117.0, "gross_charge": 180.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100122", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82040", "type": "HCPCS" } ], "description": "Hc Albumin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100123", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82042", "type": "HCPCS" } ], "description": "Hc Albumin Other Source, Quant, Ea Spec", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.7, "gross_charge": 178.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100124", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82043", "type": "HCPCS" } ], "description": "Hc Microalbumin Urine Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.9, "gross_charge": 86.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100127", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82085", "type": "HCPCS" } ], "description": "Hc Aldolase So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17.55, "gross_charge": 27.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100128", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82088", "type": "HCPCS" } ], "description": "Hc Aldosterone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37.05, "gross_charge": 57.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100129", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82103", "type": "HCPCS" } ], "description": "Hc Alpha 1 Antitrypsin Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.05, "gross_charge": 117.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100130", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82104", "type": "HCPCS" } ], "description": "Hc Alpha-1 Antitrypsin Phenotype So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 78.0, "gross_charge": 120.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100131", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82105", "type": "HCPCS" } ], "description": "Hc Alpha Fetoprotein Serum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100132", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82106", "type": "HCPCS" } ], "description": "Hc Alpha Fetoprotein Amniotic Fluid So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 96.2, "gross_charge": 148.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100133", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82107", "type": "HCPCS" } ], "description": "Hc Afp L3 Fract Isoform And Total Afp W Ratio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 189.15, "gross_charge": 291.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100134", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82108", "type": "HCPCS" } ], "description": "Hc Aluminum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.75, "gross_charge": 115.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100137", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82131", "type": "HCPCS" } ], "description": "Hc Amino Acids Single Quantitative Ea Specimen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 308.75, "gross_charge": 475.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100138", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82135", "type": "HCPCS" } ], "description": "Hc Aminolevulinic Acid Ala So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.9, "gross_charge": 206.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100139", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82136", "type": "HCPCS" } ], "description": "Hc Amino Acids Quantitative 2-5 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 150.15, "gross_charge": 231.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100140", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82139", "type": "HCPCS" } ], "description": "Hc Amino Acids Quant More Than 5 Plasma Or Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 329.55, "gross_charge": 507.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100141", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82140", "type": "HCPCS" } ], "description": "Hc Ammonia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100143", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80324", "type": "HCPCS" } ], "description": "Hc Amphetamine Or Methamphetamine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.1, "gross_charge": 114.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100144", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82150", "type": "HCPCS" } ], "description": "Hc Amylase", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.95, "gross_charge": 83.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100146", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82157", "type": "HCPCS" } ], "description": "Hc Androstenedione So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.1, "gross_charge": 74.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100148", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82164", "type": "HCPCS" } ], "description": "Hc Angiotensin I Converting Enzyme So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100149", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82172", "type": "HCPCS" } ], "description": "Hc Apolipoprotein A 1 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 61.1, "gross_charge": 94.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100150", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82175", "type": "HCPCS" } ], "description": "Hc Arsenic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 166.4, "gross_charge": 256.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100151", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82180", "type": "HCPCS" } ], "description": "Hc Vitamin C (Ascorbic Acid) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.3, "gross_charge": 102.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100152", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82525", "type": "HCPCS" } ], "description": "Hc Atomic Absorption Spectroscopy Ea Analyte So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 262.6, "gross_charge": 404.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100154", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82232", "type": "HCPCS" } ], "description": "Hc Beta 2 Microglobulin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 156.0, "gross_charge": 240.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100155", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82239", "type": "HCPCS" } ], "description": "Hc Bile Acids Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100157", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82247", "type": "HCPCS" } ], "description": "Hc Bilirubin Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100158", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82248", "type": "HCPCS" } ], "description": "Hc Bilirubin Direct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 45.5, "gross_charge": 70.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100159", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82270", "type": "HCPCS" } ], "description": "Hc Occult Blood Stool", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.8, "gross_charge": 72.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100160", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82271", "type": "HCPCS" } ], "description": "Hc Gastrocult Gastric", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 45.5, "gross_charge": 70.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100161", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82272", "type": "HCPCS" } ], "description": "Hc Occult Blood Stool 1-3 Simult Det", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100162", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82300", "type": "HCPCS" } ], "description": "Hc Cadmium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.65, "gross_charge": 201.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100163", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82306", "type": "HCPCS" } ], "description": "Hc Vitamin D Total 25-Oh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.1, "gross_charge": 134.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100164", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82308", "type": "HCPCS" } ], "description": "Hc Calcitonin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.2, "gross_charge": 68.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100165", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82310", "type": "HCPCS" } ], "description": "Hc Calcium Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100166", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82330", "type": "HCPCS" } ], "description": "Hc Calcium Ionized", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100167", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82340", "type": "HCPCS" } ], "description": "Hc Calcium Urine Timed", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 56.55, "gross_charge": 87.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100169", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82373", "type": "HCPCS" } ], "description": "Hc Carbohydrate Deficient Transferrin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 96.2, "gross_charge": 148.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100170", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82374", "type": "HCPCS" } ], "description": "Hc Bicarbonate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100171", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82375", "type": "HCPCS" } ], "description": "Hc Carboxyhemoglobin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.75, "gross_charge": 115.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100172", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82378", "type": "HCPCS" } ], "description": "Hc Cea", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 96.85, "gross_charge": 149.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100174", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82380", "type": "HCPCS" } ], "description": "Hc Carotene So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 330.2, "gross_charge": 508.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100178", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82390", "type": "HCPCS" } ], "description": "Hc Ceruloplasmin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.75, "gross_charge": 115.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100181", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82435", "type": "HCPCS" } ], "description": "Hc Chloride Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100182", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82436", "type": "HCPCS" } ], "description": "Hc Chloride Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100183", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82438", "type": "HCPCS" } ], "description": "Hc Chloride Body Fluid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100184", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82441", "type": "HCPCS" } ], "description": "Hc Chlorinated Hydrocarbons Screen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 251.55, "gross_charge": 387.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100186", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82480", "type": "HCPCS" } ], "description": "Hc Cholinesterase Serum So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.15, "gross_charge": 31.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100187", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82482", "type": "HCPCS" } ], "description": "Hc Cholinesterase Rbc So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.25, "gross_charge": 65.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100191", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82542", "type": "HCPCS" } ], "description": "Hc Chromatography Qn Column Multi", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 567.45, "gross_charge": 873.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100192", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82495", "type": "HCPCS" } ], "description": "Hc Chromium So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 104.65, "gross_charge": 161.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100193", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82507", "type": "HCPCS" } ], "description": "Hc Citrate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31.85, "gross_charge": 49.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100194", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80353", "type": "HCPCS" } ], "description": "Hc Cocaine Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.8, "gross_charge": 112.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100195", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82523", "type": "HCPCS" } ], "description": "Hc Collagen Cross Links Any Method So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 219.7, "gross_charge": 338.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100196", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82525", "type": "HCPCS" } ], "description": "Hc Copper So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.9, "gross_charge": 86.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100198", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82530", "type": "HCPCS" } ], "description": "Hc Cortisol Free", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 195.65, "gross_charge": 301.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100199", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82533", "type": "HCPCS" } ], "description": "Hc Cortisol Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.8, "gross_charge": 72.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100200", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82540", "type": "HCPCS" } ], "description": "Hc Creatine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 39.0, "gross_charge": 60.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100205", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82550", "type": "HCPCS" } ], "description": "Hc Cpk", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.25, "gross_charge": 65.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100206", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82552", "type": "HCPCS" } ], "description": "Hc Cpk Isoenzymes So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100207", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82553", "type": "HCPCS" } ], "description": "Hc Cpk Mb Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 41.6, "gross_charge": 64.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100208", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82565", "type": "HCPCS" } ], "description": "Hc Creatinine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100210", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82575", "type": "HCPCS" } ], "description": "Hc Creatinine Clearance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31.2, "gross_charge": 48.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100211", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82585", "type": "HCPCS" } ], "description": "Hc Cryofibrinogen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.05, "gross_charge": 117.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100212", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82595", "type": "HCPCS" } ], "description": "Hc Cryoglobulin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 70.2, "gross_charge": 108.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100213", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82600", "type": "HCPCS" } ], "description": "Hc Cyanide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.15, "gross_charge": 191.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100214", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82607", "type": "HCPCS" } ], "description": "Hc Vitamin B 12", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.3, "gross_charge": 62.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100215", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82608", "type": "HCPCS" } ], "description": "Hc Vitamin B 12 Binding So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 297.05, "gross_charge": 457.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100216", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82610", "type": "HCPCS" } ], "description": "Hc Cystatin C So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.2, "gross_charge": 128.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100217", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82626", "type": "HCPCS" } ], "description": "Hc Dhea So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.3, "gross_charge": 62.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100218", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82627", "type": "HCPCS" } ], "description": "Hc Dhea Sulfate Dhea S", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.2, "gross_charge": 88.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100219", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82633", "type": "HCPCS" } ], "description": "Hc Desoxycorticosteroid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 503.75, "gross_charge": 775.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100220", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82634", "type": "HCPCS" } ], "description": "Hc Deoxycortisol 11 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 77.35, "gross_charge": 119.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100221", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82638", "type": "HCPCS" } ], "description": "Hc Dibucaine Number", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.9, "gross_charge": 126.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100223", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80327", "type": "HCPCS" } ], "description": "Hc Dihydrotestosterone Dht", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 91.0, "gross_charge": 140.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100224", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82652", "type": "HCPCS" } ], "description": "Hc Vitamin D (1 25 Dihydroxy)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 86.45, "gross_charge": 133.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100225", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82656", "type": "HCPCS" } ], "description": "Hc Pancreatic Elastase 1 (Pe1) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 156.0, "gross_charge": 240.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100228", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82664", "type": "HCPCS" } ], "description": "Hc Electrophoresis Nes So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 122.85, "gross_charge": 189.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100229", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82668", "type": "HCPCS" } ], "description": "Hc Erythropoietin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.85, "gross_charge": 89.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100230", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82670", "type": "HCPCS" } ], "description": "Hc Estradiol; Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100232", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82677", "type": "HCPCS" } ], "description": "Hc Estriol", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 221.0, "gross_charge": 340.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100233", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82679", "type": "HCPCS" } ], "description": "Hc Estrone", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 317.2, "gross_charge": 488.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100235", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82693", "type": "HCPCS" } ], "description": "Hc Ethylene Glycol So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 176.15, "gross_charge": 271.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100238", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82725", "type": "HCPCS" } ], "description": "Hc Fatty Acids Nonesterified So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.7, "gross_charge": 98.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100240", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82728", "type": "HCPCS" } ], "description": "Hc Ferritin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.3, "gross_charge": 62.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100241", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82731", "type": "HCPCS" } ], "description": "Hc Fetal Fibronectin (Ffn)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 174.85, "gross_charge": 269.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100242", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82735", "type": "HCPCS" } ], "description": "Hc Fluoride So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 125.45, "gross_charge": 193.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100244", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82746", "type": "HCPCS" } ], "description": "Hc Folic Acid Serum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.3, "gross_charge": 62.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100245", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82747", "type": "HCPCS" } ], "description": "Hc Folate For Rbc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100246", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82757", "type": "HCPCS" } ], "description": "Hc Fructose Semen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 201.5, "gross_charge": 310.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100247", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82760", "type": "HCPCS" } ], "description": "Hc Galactose So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 723.45, "gross_charge": 1113.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100250", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82785", "type": "HCPCS" } ], "description": "Hc Ige Immunoglobulins So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26.65, "gross_charge": 41.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100251", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82787", "type": "HCPCS" } ], "description": "Hc Immunoglobulin Subclasses Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.95, "gross_charge": 83.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100252", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82800", "type": "HCPCS" } ], "description": "Hc Ph Blood Gas", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 61.75, "gross_charge": 95.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100253", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82803", "type": "HCPCS" } ], "description": "Hc Arterial Blood Gases", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.15, "gross_charge": 111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100254", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82805", "type": "HCPCS" } ], "description": "Hc Abg With Direct O2 Saturation Pulm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.15, "gross_charge": 111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100255", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82810", "type": "HCPCS" } ], "description": "Hc O2 Saturation Direct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100258", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82941", "type": "HCPCS" } ], "description": "Hc Gastrin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.1, "gross_charge": 54.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100259", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82943", "type": "HCPCS" } ], "description": "Hc Glucagon So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 92.95, "gross_charge": 143.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100260", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82945", "type": "HCPCS" } ], "description": "Hc Glucose Body Fluid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100261", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Glucose Quantitative Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100262", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82950", "type": "HCPCS" } ], "description": "Hc Glucose Post Glucose Dose", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100263", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82951", "type": "HCPCS" } ], "description": "Hc Glucose Tolerance 1St 3 Specimen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.9, "gross_charge": 46.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100264", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82952", "type": "HCPCS" } ], "description": "Hc Glucose Tolerance Addl Specimen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100265", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82955", "type": "HCPCS" } ], "description": "Hc G6Pd Enzyme Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 60.45, "gross_charge": 93.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100268", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82977", "type": "HCPCS" } ], "description": "Hc Glutramyltransferase Gamma Ggt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100271", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83001", "type": "HCPCS" } ], "description": "Hc Fsh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25.35, "gross_charge": 39.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100272", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83002", "type": "HCPCS" } ], "description": "Hc Luteinizing Hormone Lh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100273", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83003", "type": "HCPCS" } ], "description": "Hc Human Growth Hormone (Hgh)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 179.4, "gross_charge": 276.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100274", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83010", "type": "HCPCS" } ], "description": "Hc Haptoglobin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100275", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83013", "type": "HCPCS" } ], "description": "Hc H Pylori Breath So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.3, "gross_charge": 102.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100278", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83020", "type": "HCPCS" } ], "description": "Hc Hemoglobin Other", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1134.25, "gross_charge": 1745.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100282", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83050", "type": "HCPCS" } ], "description": "Hc Methemoglobin Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100283", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83051", "type": "HCPCS" } ], "description": "Hc Hemoglobin Plasma", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.65, "gross_charge": 201.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100284", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83068", "type": "HCPCS" } ], "description": "Hc Hemoglobin Stability Screen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100285", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83070", "type": "HCPCS" } ], "description": "Hc Hemosiderin Qualitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 377.0, "gross_charge": 580.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100287", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83088", "type": "HCPCS" } ], "description": "Hc Histamine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 218.4, "gross_charge": 336.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100288", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83090", "type": "HCPCS" } ], "description": "Hc Homocysteine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 219.05, "gross_charge": 337.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100289", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83150", "type": "HCPCS" } ], "description": "Hc Homovanillic Acid Hva So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 65.0, "gross_charge": 100.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100290", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83491", "type": "HCPCS" } ], "description": "Hc 17-Hydroxycorticosteroid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 352.95, "gross_charge": 543.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100291", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83497", "type": "HCPCS" } ], "description": "Hc Hydroxyindolacetic Acid (5-Hiaa) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.3, "gross_charge": 102.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100292", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83498", "type": "HCPCS" } ], "description": "Hc 17-Hydroxyprogesterone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100295", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83516", "type": "HCPCS" } ], "description": "Hc Immunoassay Noninfectious Agent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.7, "gross_charge": 318.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100296", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83519", "type": "HCPCS" } ], "description": "Hc Immunassay Noninfect Agnt Qnt Ria", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 371.15, "gross_charge": 571.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100297", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83520", "type": "HCPCS" } ], "description": "Hc Immunassay Noninfect Agnt Qnt Nos", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 299.0, "gross_charge": 460.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100298", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83525", "type": "HCPCS" } ], "description": "Hc Insulin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100299", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83527", "type": "HCPCS" } ], "description": "Hc Insulin Free So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.05, "gross_charge": 157.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100300", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83540", "type": "HCPCS" } ], "description": "Hc Iron", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100301", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83550", "type": "HCPCS" } ], "description": "Hc Iron Binding Capacity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100303", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83586", "type": "HCPCS" } ], "description": "Hc 17 Ketosteroids Total 24Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 165.1, "gross_charge": 254.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100305", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83605", "type": "HCPCS" } ], "description": "Hc Lactic Acid Lactate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51.35, "gross_charge": 79.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100306", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83615", "type": "HCPCS" } ], "description": "Hc Ldh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16.25, "gross_charge": 25.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100307", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83625", "type": "HCPCS" } ], "description": "Hc Ldh Isoenzymes So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.15, "gross_charge": 191.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100308", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83630", "type": "HCPCS" } ], "description": "Hc Lactoferrin Detection So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 209.3, "gross_charge": 322.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100309", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83632", "type": "HCPCS" } ], "description": "Hc Lactogen Placental So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 263.25, "gross_charge": 405.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100311", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83661", "type": "HCPCS" } ], "description": "Hc L S Ratio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 377.0, "gross_charge": 580.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100313", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83664", "type": "HCPCS" } ], "description": "Hc Lamellar Body Count", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.7, "gross_charge": 98.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100315", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83690", "type": "HCPCS" } ], "description": "Hc Lipase", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.1, "gross_charge": 74.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100316", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83695", "type": "HCPCS" } ], "description": "Hc Lipoprotein A", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100318", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83700", "type": "HCPCS" } ], "description": "Hc Lipoprotein Electrophoresis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100319", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83701", "type": "HCPCS" } ], "description": "Hc Lipoprotein High Res Fract And Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.7, "gross_charge": 178.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100320", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83704", "type": "HCPCS" } ], "description": "Hc Nmr Lipoprofile & Particles So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 70.85, "gross_charge": 109.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100321", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83718", "type": "HCPCS" } ], "description": "Hc Cholesterol Hdl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100322", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83719", "type": "HCPCS" } ], "description": "Hc Cholesterol Vldl Chylomicrons", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100323", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83721", "type": "HCPCS" } ], "description": "Hc Cholesterol Ldl Direct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100324", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83727", "type": "HCPCS" } ], "description": "Hc Gonadotropin Releasing Hormone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 490.75, "gross_charge": 755.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100325", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83735", "type": "HCPCS" } ], "description": "Hc Magnesium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100327", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83789", "type": "HCPCS" } ], "description": "Hc Mass Spectrometry Qual/Quan So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.85, "gross_charge": 409.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100330", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83825", "type": "HCPCS" } ], "description": "Hc Mercury So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100331", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83835", "type": "HCPCS" } ], "description": "Hc Metanephrines Fractionated So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100332", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80358", "type": "HCPCS" } ], "description": "Hc Methadone Dolophine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 126.1, "gross_charge": 194.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100333", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80339", "type": "HCPCS" } ], "description": "Hc Methsuximide", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 154.7, "gross_charge": 238.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100336", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83874", "type": "HCPCS" } ], "description": "Hc Myoglobin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.95, "gross_charge": 123.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100337", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83876", "type": "HCPCS" } ], "description": "Hc Myeloperoxidase Antibody", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100338", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83880", "type": "HCPCS" } ], "description": "Hc Brain Natriuretic Peptide Bnp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 174.85, "gross_charge": 269.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100339", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83883", "type": "HCPCS" } ], "description": "Hc Nephelometry Each Analyte", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 162.5, "gross_charge": 250.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100340", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83885", "type": "HCPCS" } ], "description": "Hc Nickel So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100341", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80323", "type": "HCPCS" } ], "description": "Hc Nicotine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 113.75, "gross_charge": 175.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100342", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83915", "type": "HCPCS" } ], "description": "Hc Nucleotidase 5 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 650.0, "gross_charge": 1000.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100343", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83916", "type": "HCPCS" } ], "description": "Hc Oligoclonal Bands So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 101.4, "gross_charge": 156.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100347", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80356", "type": "HCPCS" } ], "description": "Hc 6 Mam Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 137.8, "gross_charge": 212.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100348", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83930", "type": "HCPCS" } ], "description": "Hc Osmolality Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 67.6, "gross_charge": 104.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100349", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83935", "type": "HCPCS" } ], "description": "Hc Osmolality Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.95, "gross_charge": 103.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100350", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83937", "type": "HCPCS" } ], "description": "Hc Osteocalcin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 89.05, "gross_charge": 137.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100353", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83970", "type": "HCPCS" } ], "description": "Hc Pth Intact", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 71.5, "gross_charge": 110.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100354", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83986", "type": "HCPCS" } ], "description": "Hc Ph Body Fluid Nes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 60.45, "gross_charge": 93.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100355", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83992", "type": "HCPCS" } ], "description": "Hc Phencyclidine Pcp So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100356", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83993", "type": "HCPCS" } ], "description": "Hc Calprotectin Fecal So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 214.5, "gross_charge": 330.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100358", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84030", "type": "HCPCS" } ], "description": "Hc Phenylalanine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 78.65, "gross_charge": 121.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100359", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84066", "type": "HCPCS" } ], "description": "Hc Acid Phosphatase Prostatic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100360", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84075", "type": "HCPCS" } ], "description": "Hc Alkaline Phosphatase Alk Phos", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100361", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84080", "type": "HCPCS" } ], "description": "Hc Alkaline Phosphatase Isoenzyme So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51.35, "gross_charge": 79.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100362", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84081", "type": "HCPCS" } ], "description": "Hc Phosphatidylglycerol", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 163.15, "gross_charge": 251.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100363", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84087", "type": "HCPCS" } ], "description": "Hc Glucose Phosphate Isomerase Rbc So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 477.1, "gross_charge": 734.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100364", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84100", "type": "HCPCS" } ], "description": "Hc Phosphorus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100365", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84105", "type": "HCPCS" } ], "description": "Hc Phosphorus Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 70.85, "gross_charge": 109.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100366", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84106", "type": "HCPCS" } ], "description": "Hc Porphobilinogen Urine Qualitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 78.65, "gross_charge": 121.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100367", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84110", "type": "HCPCS" } ], "description": "Hc Porphobilinogen Urine Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 58.5, "gross_charge": 90.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100368", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84112", "type": "HCPCS" } ], "description": "Hc Rapid Rom Test", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 382.2, "gross_charge": 588.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100370", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84120", "type": "HCPCS" } ], "description": "Hc Porphyrin Urine Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 204.1, "gross_charge": 314.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100371", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84126", "type": "HCPCS" } ], "description": "Hc Porphyrins Feces Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 246.35, "gross_charge": 379.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100373", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84132", "type": "HCPCS" } ], "description": "Hc Potassium Serum Plasma Or Whole Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100374", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84133", "type": "HCPCS" } ], "description": "Hc Potassium Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100375", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84134", "type": "HCPCS" } ], "description": "Hc Prealbumin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.85, "gross_charge": 89.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100376", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84140", "type": "HCPCS" } ], "description": "Hc Pregnenolone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.8, "gross_charge": 112.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100377", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84143", "type": "HCPCS" } ], "description": "Hc 17 Hydroxypregnenolone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 145.6, "gross_charge": 224.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100378", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84144", "type": "HCPCS" } ], "description": "Hc Progesterone", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25.35, "gross_charge": 39.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100379", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84145", "type": "HCPCS" } ], "description": "Hc Procalcitonin Pct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 418.6, "gross_charge": 644.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100380", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84146", "type": "HCPCS" } ], "description": "Hc Prolactin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26.65, "gross_charge": 41.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100381", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84150", "type": "HCPCS" } ], "description": "Hc Prostaglandin Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 119.6, "gross_charge": 184.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100382", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84153", "type": "HCPCS" } ], "description": "Hc Psa Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 54.6, "gross_charge": 84.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100383", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84154", "type": "HCPCS" } ], "description": "Hc Psa Free", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 54.6, "gross_charge": 84.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100384", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84155", "type": "HCPCS" } ], "description": "Hc Protein Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100385", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84156", "type": "HCPCS" } ], "description": "Hc Protein Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100388", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84165", "type": "HCPCS" } ], "description": "Hc Protein Electrophoresis Serum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 205.4, "gross_charge": 316.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100389", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84166", "type": "HCPCS" } ], "description": "Hc Protein Electrophoresis Body Fluid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.7, "gross_charge": 378.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100391", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84182", "type": "HCPCS" } ], "description": "Hc Western Blot Immuno Probe Band Id", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 410.8, "gross_charge": 632.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100392", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84202", "type": "HCPCS" } ], "description": "Hc Protoporphyrin Rbc Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 251.55, "gross_charge": 387.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100393", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84203", "type": "HCPCS" } ], "description": "Hc Protoporphyrin Rbc Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 274.3, "gross_charge": 422.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100394", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84206", "type": "HCPCS" } ], "description": "Hc Proinsulin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 65.0, "gross_charge": 100.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100395", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84207", "type": "HCPCS" } ], "description": "Hc Vitamin B 6 Pyridoxal Phos So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.7, "gross_charge": 78.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100396", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84210", "type": "HCPCS" } ], "description": "Hc Pyruvic Acid So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.8, "gross_charge": 72.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100397", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84220", "type": "HCPCS" } ], "description": "Hc Pyruvate Kinase So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100403", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84252", "type": "HCPCS" } ], "description": "Hc Vitamin B 2 Riboflavin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100404", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84255", "type": "HCPCS" } ], "description": "Hc Selenium So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.1, "gross_charge": 54.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100405", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84260", "type": "HCPCS" } ], "description": "Hc Serotonin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.3, "gross_charge": 102.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100406", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84270", "type": "HCPCS" } ], "description": "Hc Sex Hormone Binding Globulin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 100.1, "gross_charge": 154.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100408", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84285", "type": "HCPCS" } ], "description": "Hc Silica So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 372.45, "gross_charge": 573.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100409", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84295", "type": "HCPCS" } ], "description": "Hc Sodium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100410", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84300", "type": "HCPCS" } ], "description": "Hc Sodium Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100411", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84302", "type": "HCPCS" } ], "description": "Hc Sodium Other", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 188.5, "gross_charge": 290.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100412", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84305", "type": "HCPCS" } ], "description": "Hc Somatomedin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 161.85, "gross_charge": 249.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100413", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84307", "type": "HCPCS" } ], "description": "Hc Somatostatin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 339.3, "gross_charge": 522.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100414", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84311", "type": "HCPCS" } ], "description": "Hc Spectrophotometry Analyte Nes So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100418", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84392", "type": "HCPCS" } ], "description": "Hc Sulfate Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.8, "gross_charge": 112.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100419", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84402", "type": "HCPCS" } ], "description": "Hc Testosterone Free", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.0, "gross_charge": 200.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100420", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84403", "type": "HCPCS" } ], "description": "Hc Testosterone Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 70.85, "gross_charge": 109.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100422", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84430", "type": "HCPCS" } ], "description": "Hc Thiocyanate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100423", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84432", "type": "HCPCS" } ], "description": "Hc Thyroglobulin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 182.0, "gross_charge": 280.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100424", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84436", "type": "HCPCS" } ], "description": "Hc T4 Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100425", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84439", "type": "HCPCS" } ], "description": "Hc T4 Free", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24.05, "gross_charge": 37.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100426", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84442", "type": "HCPCS" } ], "description": "Hc Thyroxin Binding Globulin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 64.35, "gross_charge": 99.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100427", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84443", "type": "HCPCS" } ], "description": "Hc Tsh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100428", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84445", "type": "HCPCS" } ], "description": "Hc Thyroid Stimulating Immunoglob So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 96.2, "gross_charge": 148.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100429", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84446", "type": "HCPCS" } ], "description": "Hc Vitamin E So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27.95, "gross_charge": 43.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100430", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84449", "type": "HCPCS" } ], "description": "Hc Transcortin Cortisol Bind Globulin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 377.0, "gross_charge": 580.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100431", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84450", "type": "HCPCS" } ], "description": "Hc Ast Sgot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100432", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84460", "type": "HCPCS" } ], "description": "Hc Alt Sgpt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100433", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84466", "type": "HCPCS" } ], "description": "Hc Transferrin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 80.6, "gross_charge": 124.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100434", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84478", "type": "HCPCS" } ], "description": "Hc Triglycerides", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100435", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84479", "type": "HCPCS" } ], "description": "Hc Thyroid Hormone Uptake Ratio T3U So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100436", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84480", "type": "HCPCS" } ], "description": "Hc T3 Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100437", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84481", "type": "HCPCS" } ], "description": "Hc T3 Free", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100438", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84482", "type": "HCPCS" } ], "description": "Hc Reverse T3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100439", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84484", "type": "HCPCS" } ], "description": "Hc Troponin Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100441", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84510", "type": "HCPCS" } ], "description": "Hc Tyrosine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.9, "gross_charge": 226.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100442", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84520", "type": "HCPCS" } ], "description": "Hc Bun", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100443", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84540", "type": "HCPCS" } ], "description": "Hc Urea Nitrogen Urine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100444", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84545", "type": "HCPCS" } ], "description": "Hc Urea Clearance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31.85, "gross_charge": 49.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100445", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84550", "type": "HCPCS" } ], "description": "Hc Uric Acid Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11.05, "gross_charge": 17.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100446", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84560", "type": "HCPCS" } ], "description": "Hc Uric Acid Other Source", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100450", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84585", "type": "HCPCS" } ], "description": "Hc Vma Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 41.6, "gross_charge": 64.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100451", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84586", "type": "HCPCS" } ], "description": "Hc Vasoactive Intestinal Peptide Vip So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 109.2, "gross_charge": 168.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100452", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84588", "type": "HCPCS" } ], "description": "Hc Vasopressin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 219.7, "gross_charge": 338.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100453", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84590", "type": "HCPCS" } ], "description": "Hc Vitamin A So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27.95, "gross_charge": 43.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100455", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84597", "type": "HCPCS" } ], "description": "Hc Vitamin K So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100456", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84600", "type": "HCPCS" } ], "description": "Hc Volatile Panel So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 200.85, "gross_charge": 309.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100457", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84630", "type": "HCPCS" } ], "description": "Hc Zinc So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18.85, "gross_charge": 29.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100458", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84681", "type": "HCPCS" } ], "description": "Hc C Peptide", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31.85, "gross_charge": 49.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100459", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84702", "type": "HCPCS" } ], "description": "Hc Hcg Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 30.55, "gross_charge": 47.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100460", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84703", "type": "HCPCS" } ], "description": "Hc Hcg Qualitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.8, "gross_charge": 32.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100490", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80156", "type": "HCPCS" } ], "description": "Hc Carbamazepine Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 89.7, "gross_charge": 138.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100491", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80184", "type": "HCPCS" } ], "description": "Hc Phenobarbital", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27.3, "gross_charge": 42.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100493", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80299", "type": "HCPCS" } ], "description": "Hc Drug Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 219.7, "gross_charge": 338.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100499", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80155", "type": "HCPCS" } ], "description": "Hc Caffeine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.9, "gross_charge": 146.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100505", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80159", "type": "HCPCS" } ], "description": "Hc Clozapine Level So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51.35, "gross_charge": 79.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100508", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80299", "type": "HCPCS" } ], "description": "Hc Drug Quantitative Nes So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.05, "gross_charge": 317.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100516", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80175", "type": "HCPCS" } ], "description": "Hc Lamotrigine Lamictal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.9, "gross_charge": 146.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100518", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80177", "type": "HCPCS" } ], "description": "Hc Levetiracetam Keppra", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 190.45, "gross_charge": 293.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100525", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80180", "type": "HCPCS" } ], "description": "Hc Mycophenolic Acid So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 54.6, "gross_charge": 84.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100530", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80171", "type": "HCPCS" } ], "description": "Hc Neurontin Gabapentin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.95, "gross_charge": 63.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100533", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80183", "type": "HCPCS" } ], "description": "Hc Oxcarbazepine Trileptal So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.8, "gross_charge": 52.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100535", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80367", "type": "HCPCS" } ], "description": "Hc Propoxyphene So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.95, "gross_charge": 163.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100543", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80199", "type": "HCPCS" } ], "description": "Hc Tiagabine Gabitril So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 86.45, "gross_charge": 133.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100551", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80203", "type": "HCPCS" } ], "description": "Hc Zonisamide Zonegran So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 70.2, "gross_charge": 108.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100552", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81206", "type": "HCPCS" } ], "description": "Hc Bcr Abl1 Gene Major Bp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 988.65, "gross_charge": 1521.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100553", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81207", "type": "HCPCS" } ], "description": "Hc Bcr/Abl 1 Gene Minor Bp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1111.5, "gross_charge": 1710.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100556", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81227", "type": "HCPCS" } ], "description": "Hc Cyp2C9 Sequence Genotype So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1186.25, "gross_charge": 1825.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100577", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82042", "type": "HCPCS" } ], "description": "Hc Albumin Othr Source, Qnt, Ea Spec", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.7, "gross_charge": 178.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100579", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80320", "type": "HCPCS" } ], "description": "Hc Alcohols", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100581", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80320", "type": "HCPCS" } ], "description": "Hc Alcohols So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100583", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82103", "type": "HCPCS" } ], "description": "Hc Alpha 1 Antitrypsin Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.2, "gross_charge": 68.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100587", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82139", "type": "HCPCS" } ], "description": "Hc Amino Acids Quant More Than 5 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 305.5, "gross_charge": 470.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100600", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82172", "type": "HCPCS" } ], "description": "Hc Apolipoprotein B", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.8, "gross_charge": 112.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100604", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82232", "type": "HCPCS" } ], "description": "Hc Beta 2 Microglobulin Fluid So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.2, "gross_charge": 88.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100608", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82330", "type": "HCPCS" } ], "description": "Hc Calcium Ionized Wb Pulm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100611", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82375", "type": "HCPCS" } ], "description": "Hc Carboxyhemoglobin Pulm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.75, "gross_charge": 115.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100613", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82378", "type": "HCPCS" } ], "description": "Hc Cea So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 269.1, "gross_charge": 414.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100615", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82384", "type": "HCPCS" } ], "description": "Hc Catecholamines Fraction So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.7, "gross_charge": 78.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100616", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82397", "type": "HCPCS" } ], "description": "Hc Chemiluminescent Assay So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.7, "gross_charge": 98.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100620", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82438", "type": "HCPCS" } ], "description": "Hc Chloride Stool So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18.85, "gross_charge": 29.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100621", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82465", "type": "HCPCS" } ], "description": "Hc Cholesterol Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100623", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82542", "type": "HCPCS" } ], "description": "Hc Chromatography Qn Column Single So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.05, "gross_charge": 377.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100665", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80366", "type": "HCPCS" } ], "description": "Hc Pregabalin Lyrica So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.75, "gross_charge": 115.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100673", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82570", "type": "HCPCS" } ], "description": "Hc Creatinine Other Source", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100689", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82784", "type": "HCPCS" } ], "description": "Hc Igg Iga Igm Immunoglobulins So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.25, "gross_charge": 125.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100691", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82784", "type": "HCPCS" } ], "description": "Hc Igg Iga Igm Immunoglobulins", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 70.85, "gross_charge": 109.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100693", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82810", "type": "HCPCS" } ], "description": "Hc Direct O2 Saturation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 100.75, "gross_charge": 155.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100701", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83020", "type": "HCPCS" } ], "description": "Hc Hemoglobin Fraction And Quant By Electrophoresis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 150.15, "gross_charge": 231.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100702", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83021", "type": "HCPCS" } ], "description": "Hc Hemoglobin Chromatography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 925.6, "gross_charge": 1424.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100703", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83036", "type": "HCPCS" } ], "description": "Hc Hemoglobin A1C", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.3, "gross_charge": 102.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100706", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83080", "type": "HCPCS" } ], "description": "Hc Hexosaminidase Total Serum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 486.85, "gross_charge": 749.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100788", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83540", "type": "HCPCS" } ], "description": "Hc Iron Liver Tissue Or Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 89.05, "gross_charge": 137.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100790", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83605", "type": "HCPCS" } ], "description": "Hc D Lactate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 118.3, "gross_charge": 182.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100797", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83655", "type": "HCPCS" } ], "description": "Hc Lead So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8.45, "gross_charge": 13.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100802", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83735", "type": "HCPCS" } ], "description": "Hc Magnesium So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100819", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80358", "type": "HCPCS" } ], "description": "Hc Methadone Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.9, "gross_charge": 126.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100821", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83874", "type": "HCPCS" } ], "description": "Hc Myoglobin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100823", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83883", "type": "HCPCS" } ], "description": "Hc Nephelometry Each Analyte So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.1, "gross_charge": 54.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100829", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80348", "type": "HCPCS" } ], "description": "Hc Buprenorphine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 64.35, "gross_charge": 99.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100830", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80354", "type": "HCPCS" } ], "description": "Hc Fentanyl So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100832", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80361", "type": "HCPCS" } ], "description": "Hc Opiates", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100834", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80361", "type": "HCPCS" } ], "description": "Hc Opiates 1 Or More So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 96.2, "gross_charge": 148.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100838", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83945", "type": "HCPCS" } ], "description": "Hc Oxalate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 95.55, "gross_charge": 147.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100850", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84146", "type": "HCPCS" } ], "description": "Hc Macroprolactin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 126.1, "gross_charge": 194.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100853", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84157", "type": "HCPCS" } ], "description": "Hc Protein Body Fluid Or Csf", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100870", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84244", "type": "HCPCS" } ], "description": "Hc Renin Activity Plasma So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 30.55, "gross_charge": 47.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100872", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84295", "type": "HCPCS" } ], "description": "Hc Sodium Wb Pulm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100884", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84376", "type": "HCPCS" } ], "description": "Hc Reducing Substance Not Glucose", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.3, "gross_charge": 82.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100885", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84376", "type": "HCPCS" } ], "description": "Hc Sugars Single Qual So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.2, "gross_charge": 68.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100888", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84402", "type": "HCPCS" } ], "description": "Hc Testosterone Free So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100892", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84439", "type": "HCPCS" } ], "description": "Hc T4 Free By Dialysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.2, "gross_charge": 88.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100910", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84999", "type": "HCPCS" } ], "description": "Hc Unlisted Chemistry Procedure So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 101.4, "gross_charge": 156.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100931", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80307", "type": "HCPCS" } ], "description": "Hc Drug Test Prsmv Chem Anlyzr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.95, "gross_charge": 123.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100933", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80305", "type": "HCPCS" } ], "description": "Hc Drug Test Prsmv Dir Opt Obs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 77.35, "gross_charge": 119.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100941", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82274", "type": "HCPCS" } ], "description": "Hc Occult Blood Fecal Ia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.85, "gross_charge": 89.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100952", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81261", "type": "HCPCS" } ], "description": "Hc Igh Gene Rearrange Analysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 612.95, "gross_charge": 943.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100953", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81264", "type": "HCPCS" } ], "description": "Hc Igk Rearrange Abn Clonal Pop", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 612.95, "gross_charge": 943.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100954", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80165", "type": "HCPCS" } ], "description": "Hc Valproic Acid Free So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.75, "gross_charge": 115.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100955", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82306", "type": "HCPCS" } ], "description": "Hc 25-Hydroxyvitamin D2 And D3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16.25, "gross_charge": 25.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100956", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82330", "type": "HCPCS" } ], "description": "Hc Calcium Ionized Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100957", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82435", "type": "HCPCS" } ], "description": "Hc Chloride Blood Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100958", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82565", "type": "HCPCS" } ], "description": "Hc Creatinine Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100959", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82803", "type": "HCPCS" } ], "description": "Hc Arterial Blood Gases Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.15, "gross_charge": 111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100960", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82805", "type": "HCPCS" } ], "description": "Hc Abg With Direct O2 Saturation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.15, "gross_charge": 111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100962", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Glucose Quantitative Pulmonary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100963", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Glucose Quantitative Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100964", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83050", "type": "HCPCS" } ], "description": "Hc Methemoglobin Quantitative Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100965", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83605", "type": "HCPCS" } ], "description": "Hc Lactic Acid Lactate Pulmonary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51.35, "gross_charge": 79.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100968", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84132", "type": "HCPCS" } ], "description": "Hc Potassium Whole Blood Pulmonary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100969", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84132", "type": "HCPCS" } ], "description": "Hc Potassium Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100977", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84484", "type": "HCPCS" } ], "description": "Hc Troponin Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25.35, "gross_charge": 39.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100978", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84520", "type": "HCPCS" } ], "description": "Hc Bun Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100994", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Glucose Quant Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30100998", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84295", "type": "HCPCS" } ], "description": "Hc Sodium Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101001", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80169", "type": "HCPCS" } ], "description": "Hc Everolimus So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101002", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81403", "type": "HCPCS" } ], "description": "Hc Mopath Level 4 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 744.9, "gross_charge": 1146.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101011", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81223", "type": "HCPCS" } ], "description": "Hc Cftr Gene Full Gene Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2135.25, "gross_charge": 3285.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101013", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81382", "type": "HCPCS" } ], "description": "Hc Hla-Dqa1", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 373.75, "gross_charge": 575.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101014", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81206", "type": "HCPCS" } ], "description": "Hc Bcr Abl1 Gene Major Bp So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 579.15, "gross_charge": 891.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101015", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81207", "type": "HCPCS" } ], "description": "Hc Bcr/Abl 1 Gene Minor Bp So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 237.9, "gross_charge": 366.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101016", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81400", "type": "HCPCS" } ], "description": "Hc Molecular Path Proc Level 1 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 709.15, "gross_charge": 1091.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101017", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81401", "type": "HCPCS" } ], "description": "Hc Mopath Level 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 357.5, "gross_charge": 550.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101018", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82150", "type": "HCPCS" } ], "description": "Hc Amylase So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101019", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82175", "type": "HCPCS" } ], "description": "Hc Arsenic So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 208.0, "gross_charge": 320.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101020", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80345", "type": "HCPCS" } ], "description": "Hc Barbiturate Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 91.65, "gross_charge": 141.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101021", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82300", "type": "HCPCS" } ], "description": "Hc Cadmium So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 67.6, "gross_charge": 104.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101022", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82365", "type": "HCPCS" } ], "description": "Hc Calculus Anlys Infrared Spectroscopy So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101023", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82379", "type": "HCPCS" } ], "description": "Hc Carnitine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 60.45, "gross_charge": 93.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101025", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82542", "type": "HCPCS" } ], "description": "Hc Col Chromotography Qual/Quan So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 198.9, "gross_charge": 306.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101026", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82530", "type": "HCPCS" } ], "description": "Hc Cortisol Free So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 36.4, "gross_charge": 56.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101029", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82657", "type": "HCPCS" } ], "description": "Hc Enzyme Act Blood Cell Tiss Non Rad Nes Ea Spec So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 189.8, "gross_charge": 292.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101030", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82679", "type": "HCPCS" } ], "description": "Hc Estrone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.15, "gross_charge": 31.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101031", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82710", "type": "HCPCS" } ], "description": "Hc Fat Lipids Stool Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.3, "gross_charge": 102.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101032", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82726", "type": "HCPCS" } ], "description": "Hc Fatty Acids Very Long Chain So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 119.6, "gross_charge": 184.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101033", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82775", "type": "HCPCS" } ], "description": "Hc Galactose Transferase G 1 Put Qn So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.15, "gross_charge": 131.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101034", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82985", "type": "HCPCS" } ], "description": "Hc Glycated Protein So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37.05, "gross_charge": 57.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101036", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83080", "type": "HCPCS" } ], "description": "Hc Hexosaminidase Total Serum So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 101.4, "gross_charge": 156.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101037", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83516", "type": "HCPCS" } ], "description": "Hc Immunoassay Noninfectious Agent So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101038", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83519", "type": "HCPCS" } ], "description": "Hc Immunassay Noninfect Agnt Qnt Ria So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 177.45, "gross_charge": 273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101040", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82963", "type": "HCPCS" } ], "description": "Hc Glucosidase Beta So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1005.55, "gross_charge": 1547.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101041", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83520", "type": "HCPCS" } ], "description": "Hc Immunassay Noninfect Agnt Qnt Nos So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.9, "gross_charge": 226.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101042", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83615", "type": "HCPCS" } ], "description": "Hc Ldh So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16.25, "gross_charge": 25.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101043", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83698", "type": "HCPCS" } ], "description": "Hc Lipoprotein Assoc Phospholipase A2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 312.0, "gross_charge": 480.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101044", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83785", "type": "HCPCS" } ], "description": "Hc Manganese So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 86.45, "gross_charge": 133.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101045", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83018", "type": "HCPCS" } ], "description": "Hc Heavy Metal Quant Nes Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 521.3, "gross_charge": 802.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101046", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83919", "type": "HCPCS" } ], "description": "Hc Organic Acids Qualitative Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101047", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83921", "type": "HCPCS" } ], "description": "Hc Organic Acid Single Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 30.55, "gross_charge": 47.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101048", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84120", "type": "HCPCS" } ], "description": "Hc Porphyrin Urine Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.3, "gross_charge": 162.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101049", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84166", "type": "HCPCS" } ], "description": "Hc Protein Electrophoresis Body Fluid So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101050", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84181", "type": "HCPCS" } ], "description": "Hc Western Blot So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 258.05, "gross_charge": 397.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101051", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84182", "type": "HCPCS" } ], "description": "Hc Western Blot Immuno Probe Band Id Sp So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 274.3, "gross_charge": 422.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101052", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84202", "type": "HCPCS" } ], "description": "Hc Protoporphyrin Rbc Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 251.55, "gross_charge": 387.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101053", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84238", "type": "HCPCS" } ], "description": "Hc Receptor Assay Non Endocrine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.7, "gross_charge": 98.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101055", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84305", "type": "HCPCS" } ], "description": "Hc Somatomedin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 30.55, "gross_charge": 47.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101056", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84378", "type": "HCPCS" } ], "description": "Hc Sugars Single Quantitative Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 177.45, "gross_charge": 273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101057", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84425", "type": "HCPCS" } ], "description": "Hc Vitamin B 1 Thiamine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.85, "gross_charge": 89.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101058", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84591", "type": "HCPCS" } ], "description": "Hc Vitamin Nos So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 351.65, "gross_charge": 541.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101061", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84702", "type": "HCPCS" } ], "description": "Hc Hcg Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.95, "gross_charge": 63.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101063", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81210", "type": "HCPCS" } ], "description": "Hc Braf Gene Mut Anlys V600E Tumor So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 965.25, "gross_charge": 1485.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101070", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80323", "type": "HCPCS" } ], "description": "Hc Alkoloids Nos So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 321.75, "gross_charge": 495.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101073", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80332", "type": "HCPCS" } ], "description": "Hc Antidepressants Class; 1- 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 221.0, "gross_charge": 340.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101075", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80335", "type": "HCPCS" } ], "description": "Hc Antidepressants Tricyclic And Other Cyclicals; 1-2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 119.6, "gross_charge": 184.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101077", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80338", "type": "HCPCS" } ], "description": "Hc Antidepressant Not Specified So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 183.3, "gross_charge": 282.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101079", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80339", "type": "HCPCS" } ], "description": "Hc Antiepileptics Nos 1 To 3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 175.5, "gross_charge": 270.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101080", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80342", "type": "HCPCS" } ], "description": "Hc Antipsychotics Nos 1 To 3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 225.55, "gross_charge": 347.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101081", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80349", "type": "HCPCS" } ], "description": "Hc Cannabinoids Natural So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.9, "gross_charge": 146.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101084", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80360", "type": "HCPCS" } ], "description": "Hc Methylphenidate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 293.8, "gross_charge": 452.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101085", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80362", "type": "HCPCS" } ], "description": "Hc Drug Screening Opioids And Opiate Analogs 1 Or 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 529.75, "gross_charge": 815.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101086", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80368", "type": "HCPCS" } ], "description": "Hc Sedative Hypnotics So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 123.5, "gross_charge": 190.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101088", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80371", "type": "HCPCS" } ], "description": "Hc Stimulants Synthetic So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 392.6, "gross_charge": 604.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101090", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80375", "type": "HCPCS" } ], "description": "Hc Drug Or Substance Definitive Qual Quant Nos 1-3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 487.5, "gross_charge": 750.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101091", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80369", "type": "HCPCS" } ], "description": "Hc Skeletal Muscle Relaxant 1 To 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 207.35, "gross_charge": 319.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101093", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80365", "type": "HCPCS" } ], "description": "Hc Oxycodone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 96.85, "gross_charge": 149.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101097", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80163", "type": "HCPCS" } ], "description": "Hc Digoxin Free So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 511.55, "gross_charge": 787.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101098", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80372", "type": "HCPCS" } ], "description": "Hc Tapentadol & Metabolite So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 135.2, "gross_charge": 208.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101099", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80373", "type": "HCPCS" } ], "description": "Hc Tramadol & Metabolite So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.1, "gross_charge": 114.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101100", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80346", "type": "HCPCS" } ], "description": "Hc Drug Screen Benzodiazepines 1-12 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 98.8, "gross_charge": 152.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101102", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82261", "type": "HCPCS" } ], "description": "Hc Biotinidase So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 45.5, "gross_charge": 70.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101103", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81318", "type": "HCPCS" } ], "description": "Hc Pms2 Gene Analysis Known Familial Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 886.6, "gross_charge": 1364.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101104", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82435", "type": "HCPCS" } ], "description": "Hc Chloride Wb Pulm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101108", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "G0103", "type": "HCPCS" } ], "description": "Hc Psa Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 54.6, "gross_charge": 84.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101109", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0003M", "type": "HCPCS" } ], "description": "Hc Nash Fibrosure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 991.9, "gross_charge": 1526.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101110", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80357", "type": "HCPCS" } ], "description": "Hc Ketamine And Norketamine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 566.15, "gross_charge": 871.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101111", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81287", "type": "HCPCS" } ], "description": "Hc Mgmt Gene Promoter Methylation Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 807.3, "gross_charge": 1242.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101112", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81288", "type": "HCPCS" } ], "description": "Hc Mlh1 Promoter Mrthlyation Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 773.5, "gross_charge": 1190.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101113", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "81202", "type": "HCPCS" } ], "description": "Hc Apc Gene Known Fam Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 827.45, "gross_charge": 1273.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101114", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83970", "type": "HCPCS" } ], "description": "Hc Pth Fnab Needle Wash\u00a0So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 126.75, "gross_charge": 195.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101115", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82777", "type": "HCPCS" } ], "description": "Hc Galectin 3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 226.85, "gross_charge": 349.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101116", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80321", "type": "HCPCS" } ], "description": "Hc Ethyl Glucuronide Etg So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 150.15, "gross_charge": 231.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101117", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80326", "type": "HCPCS" } ], "description": "Hc Amphetamines 5 Or More So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 293.8, "gross_charge": 452.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101118", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80347", "type": "HCPCS" } ], "description": "Hc Benzodiazepines 13 Or More So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 148.85, "gross_charge": 229.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101120", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81229", "type": "HCPCS" } ], "description": "Hc Cytogen M Array Copy No And Snp So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3109.6, "gross_charge": 4784.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101121", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81402", "type": "HCPCS" } ], "description": "Hc Mopath Procedure Level 3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1378.0, "gross_charge": 2120.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101122", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81405", "type": "HCPCS" } ], "description": "Hc Mopath Procedure Level 6 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2653.95, "gross_charge": 4083.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101123", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81406", "type": "HCPCS" } ], "description": "Hc Mopath Level 7 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2975.05, "gross_charge": 4577.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101124", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85390", "type": "HCPCS" } ], "description": "Hc Fibrinolysis Or Coagulopathy Screen, Interp And Rpt So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 75.4, "gross_charge": 116.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101126", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81405", "type": "HCPCS" } ], "description": "Hc Mopath Procedure Level 6 Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5192.2, "gross_charge": 7988.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101128", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87153", "type": "HCPCS" } ], "description": "Hc Aerobe Ident By Sequencing So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 220.35, "gross_charge": 339.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101130", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81219", "type": "HCPCS" } ], "description": "Hc Calr Gene Analysis Common Variants Exon9 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 526.5, "gross_charge": 810.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101132", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82570", "type": "HCPCS" } ], "description": "Hc Creatinine W Microalbumin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101133", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84436", "type": "HCPCS" } ], "description": "Hc T4 Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.25, "gross_charge": 225.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101134", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81314", "type": "HCPCS" } ], "description": "Hc Pdgfra Mutation Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1155.7, "gross_charge": 1778.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101135", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81273", "type": "HCPCS" } ], "description": "Hc Kit Gene Analys D816 Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 870.35, "gross_charge": 1339.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101136", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81435", "type": "HCPCS" } ], "description": "Hc Hrditary Colon Ca Dsrdrs Gen Seq Analys 10 Gen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5607.55, "gross_charge": 8627.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101137", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81235", "type": "HCPCS" } ], "description": "Hc Egfr Gene Com Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1228.5, "gross_charge": 1890.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101138", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81272", "type": "HCPCS" } ], "description": "Hc Kit Gene Targeted Seq Analys So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1821.95, "gross_charge": 2803.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101139", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80352", "type": "HCPCS" } ], "description": "Hc Cannabinoids Synthetic 7 Or More So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 280.15, "gross_charge": 431.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101141", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81311", "type": "HCPCS" } ], "description": "Hc Nras Gene Variants Exon 2 And 3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 721.5, "gross_charge": 1110.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101142", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81407", "type": "HCPCS" } ], "description": "Hc Mopath Procedure Level 8 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1789.45, "gross_charge": 2753.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101143", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80320", "type": "HCPCS" } ], "description": "Hc Ml Alcohols So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101144", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80321", "type": "HCPCS" } ], "description": "Hc Ml Alcohol Biomarkers; 1-2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101145", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80323", "type": "HCPCS" } ], "description": "Hc Ml Alkaloids Nos So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101146", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80324", "type": "HCPCS" } ], "description": "Hc Ml Amphetamines; 1 Or 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101147", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80327", "type": "HCPCS" } ], "description": "Hc Ml Anabolic Steroids; 1-2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101148", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80329", "type": "HCPCS" } ], "description": "Hc Ml Analgesics Non-Opiod; 1-2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101149", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80332", "type": "HCPCS" } ], "description": "Hc Ml Antidepressants, Serotonergic Class; 1 Or 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101150", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80335", "type": "HCPCS" } ], "description": "Hc Ml Antidepressants, Tricyclic And Other Cyclicals; 1 Or 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101151", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80338", "type": "HCPCS" } ], "description": "Hc Ml Antidepressants Nos So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101152", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80339", "type": "HCPCS" } ], "description": "Hc Ml Antiepileptics Nos; 1-3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101153", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80342", "type": "HCPCS" } ], "description": "Hc Ml Antipsychotics Nos; 1-3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101154", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80345", "type": "HCPCS" } ], "description": "Hc Ml Barbiturates So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101155", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80346", "type": "HCPCS" } ], "description": "Hc Ml Benzodiazepines; 1-12 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101156", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80348", "type": "HCPCS" } ], "description": "Hc Ml Buprenorphine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101157", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80349", "type": "HCPCS" } ], "description": "Hc Ml Cannabinoids Natural So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101158", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80352", "type": "HCPCS" } ], "description": "Hc Ml Cannabinoids Synthetic; 7 Or More So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101159", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80353", "type": "HCPCS" } ], "description": "Hc Ml Cocaine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101160", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80354", "type": "HCPCS" } ], "description": "Hc Ml Fentanyl So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101161", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80355", "type": "HCPCS" } ], "description": "Hc Ml Gabapentin Non-Blood So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101162", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80356", "type": "HCPCS" } ], "description": "Hc Ml Heroin Metabolite So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101163", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80357", "type": "HCPCS" } ], "description": "Hc Ml Ketamine And Norketamine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101164", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80358", "type": "HCPCS" } ], "description": "Hc Ml Methadone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101165", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80359", "type": "HCPCS" } ], "description": "Hc Ml Methylenedioxyamphetamines (Mda, Mdea, Mdma) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101166", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80360", "type": "HCPCS" } ], "description": "Hc Ml Methylphenidate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101167", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80361", "type": "HCPCS" } ], "description": "Hc Ml Opiates, 1+ So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101168", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80362", "type": "HCPCS" } ], "description": "Hc Ml Opiods And Opiate Analogs; 1 - 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101169", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80365", "type": "HCPCS" } ], "description": "Hc Ml Oxycodone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101170", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83992", "type": "HCPCS" } ], "description": "Hc Ml Phencyclidine (Pcp) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101171", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80366", "type": "HCPCS" } ], "description": "Hc Ml Pregabalin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101172", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80367", "type": "HCPCS" } ], "description": "Hc Ml Propoxyphene So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101173", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80368", "type": "HCPCS" } ], "description": "Hc Ml Sedative Hypnotics Non-Benzodiazepines So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101174", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80369", "type": "HCPCS" } ], "description": "Hc Ml Skeletal Muscle Relaxants; 1 - 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101175", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80371", "type": "HCPCS" } ], "description": "Hc Ml Stimulants Synthetic So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101176", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80372", "type": "HCPCS" } ], "description": "Hc Ml Tapentadol & Metabolite So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101177", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80373", "type": "HCPCS" } ], "description": "Hc Ml Tramadol So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101178", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80374", "type": "HCPCS" } ], "description": "Hc Ml Stereoisomer (Enantiomer) Anlys, Sgl Drug Class So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101179", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80375", "type": "HCPCS" } ], "description": "Hc Ml Drugs Or Substances, Defin, Ql Or Qt; 1-3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101180", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81170", "type": "HCPCS" } ], "description": "Hc Abl1 Gene Analysis Kinase Domain Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 614.25, "gross_charge": 945.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101181", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81218", "type": "HCPCS" } ], "description": "Hc Cebpa Gene Full Sequence So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 874.25, "gross_charge": 1345.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101182", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81246", "type": "HCPCS" } ], "description": "Hc Flt3 Tkd Gene Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 434.85, "gross_charge": 669.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101183", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81445", "type": "HCPCS" } ], "description": "Hc Gen Seq Analys Solid Organ Neoplasm 5-50 Gene So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3953.95, "gross_charge": 6083.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101185", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80307", "type": "HCPCS" } ], "description": "Hc Drug Test Prsmv Chem Anlyzer So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.2, "gross_charge": 128.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101194", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84410", "type": "HCPCS" } ], "description": "Hc Testosterone Bioavailable So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 71.5, "gross_charge": 110.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101195", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "81450", "type": "HCPCS" } ], "description": "Hc Tgsap Hematolymphoid Neo/Do 5-50 Genes Rna Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4650.75, "gross_charge": 7155.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101196", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83070", "type": "HCPCS" } ], "description": "Hc Hemosiderin Qual So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.2, "gross_charge": 68.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101197", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84478", "type": "HCPCS" } ], "description": "Hc Triglycerides So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.9, "gross_charge": 86.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101198", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80048", "type": "HCPCS" } ], "description": "Hc Fsed Basic Metabolic Panel Calcium Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 36.4, "gross_charge": 56.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101199", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80053", "type": "HCPCS" } ], "description": "Hc Fsed Comprehensive Metabolic Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.1, "gross_charge": 74.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101200", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80069", "type": "HCPCS" } ], "description": "Hc Fsed Renal Function Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.9, "gross_charge": 66.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101201", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80305", "type": "HCPCS" } ], "description": "Hc Fsed Drug Test Prsmv Dir Opt Obs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 77.35, "gross_charge": 119.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101202", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82040", "type": "HCPCS" } ], "description": "Hc Fsed Albumin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101203", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82150", "type": "HCPCS" } ], "description": "Hc Fsed Amylase", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.95, "gross_charge": 83.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101204", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82247", "type": "HCPCS" } ], "description": "Hc Fsed Bilirubin Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101205", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82270", "type": "HCPCS" } ], "description": "Hc Fsed Occult Blood Stool", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.8, "gross_charge": 72.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101206", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82271", "type": "HCPCS" } ], "description": "Hc Fsed Gastrocult Gastric", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 45.5, "gross_charge": 70.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101207", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82330", "type": "HCPCS" } ], "description": "Hc Fsed Calcium Ionized", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101208", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82435", "type": "HCPCS" } ], "description": "Hc Fsed Chloride Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101209", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82565", "type": "HCPCS" } ], "description": "Hc Fsed Creatinine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101210", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82803", "type": "HCPCS" } ], "description": "Hc Fsed Arterial Blood Gases", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.15, "gross_charge": 111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101211", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Fsed Glucose Quantitative Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101212", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82977", "type": "HCPCS" } ], "description": "Hc Fsed Glutramyltransferase Gamma Ggt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101213", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83605", "type": "HCPCS" } ], "description": "Hc Fsed Lactic Acid Lactate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51.35, "gross_charge": 79.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101214", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83735", "type": "HCPCS" } ], "description": "Hc Fsed Magnesium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101215", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83880", "type": "HCPCS" } ], "description": "Hc Fsed Brain Natriuretic Peptide Bnp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 174.85, "gross_charge": 269.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101216", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84075", "type": "HCPCS" } ], "description": "Hc Fsed Alkaline Phosphatase Alk Phos", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101217", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84132", "type": "HCPCS" } ], "description": "Hc Fsed Potassium Serum Plasma Or Whole Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101218", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84155", "type": "HCPCS" } ], "description": "Hc Fsed Protein Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101219", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84295", "type": "HCPCS" } ], "description": "Hc Fsed Sodium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101220", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84450", "type": "HCPCS" } ], "description": "Hc Fsed Ast Sgot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101221", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84460", "type": "HCPCS" } ], "description": "Hc Fsed Alt Sgpt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101222", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84484", "type": "HCPCS" } ], "description": "Hc Fsed Troponin Quantitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101223", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84703", "type": "HCPCS" } ], "description": "Hc Fsed Hcg Qualitative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.8, "gross_charge": 32.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101224", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81460", "type": "HCPCS" } ], "description": "Hc Whole Mitochondrial Genome So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4037.8, "gross_charge": 6212.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101225", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81276", "type": "HCPCS" } ], "description": "Hc Kras Gene Addl Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 443.95, "gross_charge": 683.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101226", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84520", "type": "HCPCS" } ], "description": "Hc Fsed Bun", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101227", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82374", "type": "HCPCS" } ], "description": "Hc Fsed Bicarbonate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101228", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82310", "type": "HCPCS" } ], "description": "Hc Fsed Calcium Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101229", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84100", "type": "HCPCS" } ], "description": "Hc Fsed Phosphorus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101230", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81162", "type": "HCPCS" } ], "description": "Hc Brca1 And 2 Seq And Full Dup/Del So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3685.5, "gross_charge": 5670.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101231", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80377", "type": "HCPCS" } ], "description": "Hc Drug/Substance Nos 7/More So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 189.15, "gross_charge": 291.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101232", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81380", "type": "HCPCS" } ], "description": "Hc Hla I Typing 1 Locus Hr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1016.6, "gross_charge": 1564.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101233", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81317", "type": "HCPCS" } ], "description": "Hc Pms2 Gene Full Seq Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1766.7, "gross_charge": 2718.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101234", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83050", "type": "HCPCS" } ], "description": "Hc Methemoglobin Blood Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.95, "gross_charge": 83.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101235", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83060", "type": "HCPCS" } ], "description": "Hc Sulfhemoglobin Blood Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.3, "gross_charge": 82.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101236", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82978", "type": "HCPCS" } ], "description": "Hc Glutathione So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 685.1, "gross_charge": 1054.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101237", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81511", "type": "HCPCS" } ], "description": "Hc Fet Con Abn Afp4 Algorithm So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.3, "gross_charge": 122.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101238", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82570", "type": "HCPCS" } ], "description": "Hc Creatinine Other Source So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 30.55, "gross_charge": 47.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101239", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80190", "type": "HCPCS" } ], "description": "Hc Procainamide Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 75.4, "gross_charge": 116.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101240", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80359", "type": "HCPCS" } ], "description": "Hc Methylenedioxyamphetamines (Mda, Mdea, Mdma) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.25, "gross_charge": 85.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101241", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80333", "type": "HCPCS" } ], "description": "Hc Antidepressants Class; 3-5 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 211.9, "gross_charge": 326.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101242", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80337", "type": "HCPCS" } ], "description": "Hc Antidepressants Tricyclic And Other Cyclicals; 6 Or More So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 119.6, "gross_charge": 184.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101243", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83915", "type": "HCPCS" } ], "description": "Hc Rbc Enzymes So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2611.7, "gross_charge": 4018.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101245", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80184", "type": "HCPCS" } ], "description": "Hc Phenobarbital So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101246", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83525", "type": "HCPCS" } ], "description": "Hc Insulin Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.8, "gross_charge": 72.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101247", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84075", "type": "HCPCS" } ], "description": "Hc Alkaline Phosphatase So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101249", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82340", "type": "HCPCS" } ], "description": "Hc Calcium Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101250", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84133", "type": "HCPCS" } ], "description": "Hc Potassium Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101251", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83935", "type": "HCPCS" } ], "description": "Hc Osmolality Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 39.0, "gross_charge": 60.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101252", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84560", "type": "HCPCS" } ], "description": "Hc Uric Acid Other Source So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.9, "gross_charge": 146.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101253", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84300", "type": "HCPCS" } ], "description": "Hc Sodium Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 67.6, "gross_charge": 104.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101254", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82436", "type": "HCPCS" } ], "description": "Hc Chloride Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22.1, "gross_charge": 34.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101255", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84105", "type": "HCPCS" } ], "description": "Hc Phosphorus Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 41.6, "gross_charge": 64.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101256", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83986", "type": "HCPCS" } ], "description": "Hc Ph Body Fluid Nos So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22.1, "gross_charge": 34.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101257", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82140", "type": "HCPCS" } ], "description": "Hc Ammonia So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 227.5, "gross_charge": 350.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101258", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84540", "type": "HCPCS" } ], "description": "Hc Urea Nitrogen Urine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101259", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "81266", "type": "HCPCS" } ], "description": "Hc Str Markers Spec Anal Addl So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 468.0, "gross_charge": 720.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101261", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82010", "type": "HCPCS" } ], "description": "Hc Ketone Bodies Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101262", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82533", "type": "HCPCS" } ], "description": "Hc Cortisol Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101263", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82728", "type": "HCPCS" } ], "description": "Hc Ferritin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 159.9, "gross_charge": 246.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101264", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83021", "type": "HCPCS" } ], "description": "Hc Hemoglobin Fraction And Quant By Chromatography So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 54.6, "gross_charge": 84.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101265", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84100", "type": "HCPCS" } ], "description": "Hc Phosphorus So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 195.0, "gross_charge": 300.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101266", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81442", "type": "HCPCS" } ], "description": "Hc Noonan Spectrum Disorders Gen Seq Analys 12 Gen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3473.6, "gross_charge": 5344.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101267", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80332", "type": "HCPCS" } ], "description": "Hc Tca; 1- 2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26.65, "gross_charge": 41.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101268", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80335", "type": "HCPCS" } ], "description": "Hc Antidepressants Tca And Other Cyclicals; 1-2 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10.4, "gross_charge": 16.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101269", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81105", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 1 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101270", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81106", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 2 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101271", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81107", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 3 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101272", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81108", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 4 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101273", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81109", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 5 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101274", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81110", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 6 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101275", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81111", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 9 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101276", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81112", "type": "HCPCS" } ], "description": "Hc Human Platelet Antigen 15 Genotyping So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101277", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81120", "type": "HCPCS" } ], "description": "Hc Idh1, Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 668.85, "gross_charge": 1029.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101278", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81121", "type": "HCPCS" } ], "description": "Hc Idh2 , Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 668.85, "gross_charge": 1029.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101281", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81230", "type": "HCPCS" } ], "description": "Hc Cyp3A4, Gene Analysis, Common Variant(S) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1015.3, "gross_charge": 1562.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101282", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81231", "type": "HCPCS" } ], "description": "Hc Cyp3A5 , Gene Analysis, Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1186.25, "gross_charge": 1825.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101283", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81232", "type": "HCPCS" } ], "description": "Hc Dpyd, Gene Analysis, Common Variant(S) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1097.2, "gross_charge": 1688.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101284", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81238", "type": "HCPCS" } ], "description": "Hc F9, Full Gene Sequence So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3723.85, "gross_charge": 5729.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101286", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81248", "type": "HCPCS" } ], "description": "Hc G6Pd, Gene Analysis; Known Familial Variant(S) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4743.05, "gross_charge": 7297.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101287", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81249", "type": "HCPCS" } ], "description": "Hc G6Pd, Gene Analysis; Full Gene Sequence So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2037.75, "gross_charge": 3135.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101289", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81259", "type": "HCPCS" } ], "description": "Hc Hba1/Hba2, Gene Analysis; Full Gene Sequence So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 891.15, "gross_charge": 1371.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101290", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81269", "type": "HCPCS" } ], "description": "Hc Hba1/Hba2, Gene Analysis; Duplication/Deletion Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 570.05, "gross_charge": 877.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101292", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81328", "type": "HCPCS" } ], "description": "Hc Slco1B1, Gene Analysis, Common Variant(S) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1015.3, "gross_charge": 1562.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101294", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81335", "type": "HCPCS" } ], "description": "Hc Tpmt, Gene Analysis, Common Variants So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 929.5, "gross_charge": 1430.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101298", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81363", "type": "HCPCS" } ], "description": "Hc Hbb, Duplication/Deletion Variant(S) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 614.25, "gross_charge": 945.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101299", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81364", "type": "HCPCS" } ], "description": "Hc Hbb, Full Gene Sequence So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 626.6, 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Seq Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4789.2, "gross_charge": 7368.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101381", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84377", "type": "HCPCS" } ], "description": "Hc Sugars Multiple Qualitative Each Spec So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 151.45, "gross_charge": 233.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101382", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82945", "type": "HCPCS" } ], "description": "Hc Glucose Body Fluid Not Blood So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": 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"facility", "discounted_cash": 536.9, "gross_charge": 826.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101436", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82642", "type": "HCPCS" } ], "description": "Hc Dihydrotestosterone (Dht) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 78.0, "gross_charge": 120.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101438", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81217", "type": "HCPCS" } ], "description": "Hc Brca2 Gene Known Fam Variant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 886.6, "gross_charge": 1364.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101439", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0070U", "type": "HCPCS" } ], "description": "Hc Cyp2D6 Gen Com&Slct Rar Vrnt So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 722.15, "gross_charge": 1111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101440", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0035U", "type": "HCPCS" } ], "description": "Hc Neuro Csf Prion Prtn Qual So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1844.7, "gross_charge": 2838.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101441", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81187", "type": "HCPCS" } ], "description": "Hc Cnbp Gene Detc Abnor Allele So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2360.15, "gross_charge": 3631.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101442", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81234", "type": "HCPCS" } ], "description": "Hc Dmpk Gene Detc Abnor Allele So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1457.3, "gross_charge": 2242.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101443", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81443", "type": "HCPCS" } ], "description": "Hc Genetic Testing For Severe Inherited Conditions So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3948.75, "gross_charge": 6075.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101444", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81252", "type": "HCPCS" } ], "description": "Hc Gjb2 Gene Full Sequence So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 775.45, "gross_charge": 1193.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101445", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84295", "type": "HCPCS" } ], "description": "Hc Mstu Sodium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101446", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84132", "type": "HCPCS" } ], "description": "Hc Mstu Potassium Serum Plasma Or Wb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101447", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82435", "type": "HCPCS" } ], "description": "Hc Mstu Chloride Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101448", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Mstu Glucose Quant Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101449", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82565", "type": "HCPCS" } ], "description": "Hc Mstu Creatinine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101450", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82330", "type": "HCPCS" } ], "description": "Hc Mstu Calcium Ionized", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101451", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83605", "type": "HCPCS" } ], "description": "Hc Mstu Lactic Acid (Lactate)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51.35, "gross_charge": 79.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101452", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84520", "type": "HCPCS" } ], "description": "Hc Mstu Bun", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101453", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82374", "type": "HCPCS" } ], "description": "Hc Mstu Bicarbonate Total (Tco2)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101454", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80047", "type": "HCPCS" } ], "description": "Hc Mstu Basic Metabolic Panel Calcium Ionized", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.95, "gross_charge": 63.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101456", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84295", "type": "HCPCS" } ], "description": "Hc Sodium Wb Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101457", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82805", "type": "HCPCS" } ], "description": "Hc Abg With Direct O2 Saturation Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.15, "gross_charge": 111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101458", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84132", "type": "HCPCS" } ], "description": "Hc Potassium Whole Blood Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101459", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Glucose Quantitative Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101460", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82435", "type": "HCPCS" } ], "description": "Hc Chloride Wb Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101461", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82330", "type": "HCPCS" } ], "description": "Hc Calcium Ionized Wb Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": 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"billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101465", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84295", "type": "HCPCS" } ], "description": "Hc Sodium Wb Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101466", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82805", "type": "HCPCS" } ], "description": "Hc Abg With Direct O2 Saturation Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.15, "gross_charge": 111.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101467", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84132", "type": "HCPCS" } ], "description": "Hc Potassium Whole Blood Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101468", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82947", "type": "HCPCS" } ], "description": "Hc Glucose Quantitative Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101469", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82435", "type": "HCPCS" } ], "description": "Hc Chloride Wb Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101470", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82330", "type": "HCPCS" } ], "description": "Hc Calcium Ionized Wb Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101471", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83605", "type": "HCPCS" } ], "description": "Hc Lactic Acid Lactate Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51.35, "gross_charge": 79.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101472", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82375", "type": "HCPCS" } ], "description": "Hc Carboxyhemoglobin Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.75, "gross_charge": 115.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101473", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83050", "type": "HCPCS" } ], "description": "Hc Methemoglobin Quantitative Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101474", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82040", "type": "HCPCS" } ], "description": "Hc Albumin Specials", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101476", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80145", "type": "HCPCS" } ], "description": "Hc Adalimumab So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 450.45, "gross_charge": 693.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101477", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80187", "type": "HCPCS" } ], "description": "Hc Posaconazole So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 127.4, "gross_charge": 196.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101478", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80230", "type": "HCPCS" } ], "description": "Hc Infliximab So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 321.75, "gross_charge": 495.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101479", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80235", "type": "HCPCS" } ], "description": "Hc Lacosamide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 203.45, "gross_charge": 313.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101480", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80280", "type": "HCPCS" } ], "description": "Hc Vedolizumab So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 750.1, "gross_charge": 1154.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101481", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80285", "type": "HCPCS" } ], "description": "Hc Voriconazole So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 166.4, "gross_charge": 256.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101482", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81277", "type": "HCPCS" } ], "description": "Hc Cytogenomic Neoplasia Microarray Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2975.05, "gross_charge": 4577.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101489", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87563", "type": "HCPCS" } ], "description": "Hc Mycoplasma Genitalium Detection By Nucleic Acid Amplified Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 175.5, "gross_charge": 270.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101490", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82810", "type": "HCPCS" } ], "description": "Hc O2 Saturation Direct Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 100.75, "gross_charge": 155.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101491", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80047", "type": "HCPCS" } ], "description": "Hc Fsed Basic Metabolic Panel Calcium, Ionized", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.95, "gross_charge": 63.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101492", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82658", "type": "HCPCS" } ], "description": "Hc Enzyme Act Blood Cell Tiss Radact Substrate Ea So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 373.1, "gross_charge": 574.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101493", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80322", "type": "HCPCS" } ], "description": "Hc Ml Alcohol Biomarkers; 3+ So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101494", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80325", "type": "HCPCS" } ], "description": "Hc Ml Amphetamines; 3-4 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101495", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80326", "type": "HCPCS" } ], "description": "Hc Ml Amphetamines; 5+ So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101496", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "81277", "type": "HCPCS" } ], "description": "Hc Cytogenomic Neoplasia Microarray Analysis Ap So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4498.65, "gross_charge": 6921.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101497", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80364", "type": "HCPCS" } ], "description": "Hc Opioid &Opiate Analog 5+ So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101498", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80333", "type": "HCPCS" } ], "description": "Hc Ml Antidepressants, Serotonergic Class; 3-5 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101499", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80336", "type": "HCPCS" } ], "description": "Hc Ml Antidepressants, Tricyclic And Other Cyclicals; 3-5 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101500", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80343", "type": "HCPCS" } ], "description": "Hc Ml Antipsychotics Nos; 4-6 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101501", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80363", "type": "HCPCS" } ], "description": "Hc Ml Opiods And Opiate Analogs; 3-4 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101502", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80364", "type": "HCPCS" } ], "description": "Hc Ml Opiods And Opiate Analogs; 5+ So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101503", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82088", "type": "HCPCS" } ], "description": "Hc Aldosterone", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.15, "gross_charge": 91.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101504", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84165", "type": "HCPCS" } ], "description": "Hc Protein Electrophoresis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101505", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80307", "type": "HCPCS" } ], "description": "Hc Drug Test Prsmv Chem Anlyzer Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 565.5, "gross_charge": 870.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101506", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86021", "type": "HCPCS" } ], "description": "Hc Wbc Antibody Identification So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 135.2, "gross_charge": 208.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101507", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80143", "type": "HCPCS" } ], "description": "Hc Drug Assay Acetaminophen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101508", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80151", "type": "HCPCS" } ], "description": "Hc Drug Assay Amiodarone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.25, "gross_charge": 65.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101509", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80161", "type": "HCPCS" } ], "description": "Hc Asy Carbamazepine; -10, 11-Epoxide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101510", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80167", "type": "HCPCS" } ], "description": "Hc Drug Assay Felbamate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 75.4, "gross_charge": 116.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101511", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80179", "type": "HCPCS" } ], "description": "Hc Drug Assay Salicylate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.65, "gross_charge": 201.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101512", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80181", "type": "HCPCS" } ], "description": "Hc Drug Assay Flecainide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 65.65, "gross_charge": 101.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101513", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80189", "type": "HCPCS" } ], "description": "Hc Drug Assay Itraconazole So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101514", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80193", "type": "HCPCS" } ], "description": "Hc Drug Assay Leflunomide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.95, "gross_charge": 103.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101515", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80204", "type": "HCPCS" } ], "description": "Hc Drug Assay Methotrexate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1040.0, "gross_charge": 1600.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101516", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80210", "type": "HCPCS" } ], "description": "Hc Drug Assay Rufinamide So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101517", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82077", "type": "HCPCS" } ], "description": "Hc Alcohol (Ethanol) Level, Except Urine And Breath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.25, "gross_charge": 225.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101518", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82681", "type": "HCPCS" } ], "description": "Hc Estradiol Free, Direct Measure So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 284.05, "gross_charge": 437.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101519", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82681", "type": "HCPCS" } ], "description": "Hc Estradiol Free, Direct Measure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 506.35, "gross_charge": 779.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101520", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80051", "type": "HCPCS" } ], "description": "Hc Fsed Electrolyte Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.9, "gross_charge": 46.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101521", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83090", "type": "HCPCS" } ], "description": "Hc Homocysteine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 54.6, "gross_charge": 84.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101522", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83918", "type": "HCPCS" } ], "description": "Hc Organic Acids Total Quant Ea Spec So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 737.1, "gross_charge": 1134.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101523", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84150", "type": "HCPCS" } ], "description": "Hc Prostaglandin Each Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 898.3, "gross_charge": 1382.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101524", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80164", "type": "HCPCS" } ], "description": "Hc Valproic Acid Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101525", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80076", "type": "HCPCS" } ], "description": "Hc Fsed Hepatic Function Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18.2, "gross_charge": 28.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101530", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80220", "type": "HCPCS" } ], "description": "Hc Drug Assay Hydroxychloroquine So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 472.55, "gross_charge": 727.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101531", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82653", "type": "HCPCS" } ], "description": "Hc Elastase Pancreatic Fecal Quantitative So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.05, "gross_charge": 317.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101532", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83521", "type": "HCPCS" } ], "description": "Hc Immunoglobulin Light Chains Free Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 136.5, "gross_charge": 210.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101533", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83521", "type": "HCPCS" } ], "description": "Hc Immunoglobulin Light Chains Free Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 351.65, "gross_charge": 541.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101534", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83529", "type": "HCPCS" } ], "description": "Hc Assay Of Interleukin-6 (Il-6) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.9, "gross_charge": 226.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101535", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83631", "type": "HCPCS" } ], "description": "Hc Lactoferrin Fecal Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 425.1, "gross_charge": 654.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101536", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83785", "type": "HCPCS" } ], "description": "Hc Manganese Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 335.4, "gross_charge": 516.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101537", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83695", "type": "HCPCS" } ], "description": "Hc Lipoprotein A So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101538", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80197", "type": "HCPCS" } ], "description": "Hc Tacrolimus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101539", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83497", "type": "HCPCS" } ], "description": "Hc Hydroxyindolacetic Acid, 5-(Hiaa) Plasma So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 974.35, "gross_charge": 1499.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101540", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82495", "type": "HCPCS" } ], "description": "Hc Chromium Whole Blood Or Fluid So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 630.5, "gross_charge": 970.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101541", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82657", "type": "HCPCS" } ], "description": "Hc Enzyme Act Blood Cell Tiss Non Rad Nes Ea Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 702.0, "gross_charge": 1080.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101542", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80349", "type": "HCPCS" } ], "description": "Hc Cannabinoids Natural Serum So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 501.15, "gross_charge": 771.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101543", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83789", "type": "HCPCS" } ], "description": "Hc Mass Spect&Tandem Mass Spect Nondrg Anal Nes Ea So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 593.45, "gross_charge": 913.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101544", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84150", "type": "HCPCS" } ], "description": "Hc Prostaglndin Each Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 620.1, "gross_charge": 954.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101545", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83864", "type": "HCPCS" } ], "description": "Hc Mucopolysaccharides Acid Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 926.9, "gross_charge": 1426.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101546", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84433", "type": "HCPCS" } ], "description": "Hc Thiopurine S-Methytransferase (Tpmt) So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 269.75, "gross_charge": 415.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101547", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82310", "type": "HCPCS" } ], "description": "Hc Calcium Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101548", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82164", "type": "HCPCS" } ], "description": "Hc Angiotensin I-Converting Enzyme, Csf So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.9, "gross_charge": 206.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101549", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82175", "type": "HCPCS" } ], "description": "Hc Arsenic Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101550", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82397", "type": "HCPCS" } ], "description": "Hc Chemiluminescent Assay Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 343.2, "gross_charge": 528.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101551", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83018", "type": "HCPCS" } ], "description": "Hc Heavy Metal Quant Nes So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 98.15, "gross_charge": 151.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101552", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83080", "type": "HCPCS" } ], "description": "Hc Hexosaminidase Total Serum Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 457.6, "gross_charge": 704.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101553", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83883", "type": "HCPCS" } ], "description": "Hc Nephelometry Each Analyte Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 97.5, "gross_charge": 150.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101554", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84210", "type": "HCPCS" } ], "description": "Hc Pyruvic Acid Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.15, "gross_charge": 191.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101555", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84702", "type": "HCPCS" } ], "description": "Hc Hcg Quantitative Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 384.15, "gross_charge": 591.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101556", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82633", "type": "HCPCS" } ], "description": "Hc Desoxycorticosteroid So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101557", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "83516", "type": "HCPCS" } ], "description": "Hc Ia Noninfectious Agent Special Facn1 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 321.75, "gross_charge": 495.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101558", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82955", "type": "HCPCS" } ], "description": "Hc G6Pd Enzyme Quant Special Eeev1 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 391.3, "gross_charge": 602.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101559", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84220", "type": "HCPCS" } ], "description": "Hc Pyruvate Kinase Special Eeev1 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 381.55, "gross_charge": 587.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101560", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82725", "type": "HCPCS" } ], "description": "Hc Fatty Acids Nonesterified Special Fapep So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 182.0, "gross_charge": 280.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101561", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82166", "type": "HCPCS" } ], "description": "Hc Assay Anti-Mullerian Hormone So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 109.85, "gross_charge": 169.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101562", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80325", "type": "HCPCS" } ], "description": "Hc Amphetamines 3-4 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.3, "gross_charge": 62.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101563", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80365", "type": "HCPCS" } ], "description": "Hc Oxycodone Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 467.35, "gross_charge": 719.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101564", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82163", "type": "HCPCS" } ], "description": "Hc Angiotensin Ii So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101565", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "80176", "type": "HCPCS" } ], "description": "Hc Lidocaine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.15, "gross_charge": 191.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101567", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "82234", "type": "HCPCS" } ], "description": "Hc Beta-Amyloid 1-42 (Abeta 42)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 570.7, "gross_charge": 878.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101569", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84393", "type": "HCPCS" } ], "description": "Hc Tau Phosphorylated Ea", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 975.0, "gross_charge": 1500.0, "setting": "both" } ] }, { "code_information": [ { "code": "30101570", "type": "CDM" }, { "code": "301", "type": "RC" }, { "code": "84394", "type": "HCPCS" } ], "description": "Hc Total Tau", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 975.0, "gross_charge": 1500.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200001", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86000", "type": "HCPCS" } ], "description": "Hc Febrile Agglutinin Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.1, "gross_charge": 74.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200006", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86023", "type": "HCPCS" } ], "description": "Hc Antibody Identification Platelet Associated Igm So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 110.5, "gross_charge": 170.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200007", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86038", "type": "HCPCS" } ], "description": "Hc Antinuclear Abs (Ana)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 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"additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24.7, "gross_charge": 38.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200012", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86141", "type": "HCPCS" } ], "description": "Hc C Reactive Protein Cardiac Risk", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24.7, "gross_charge": 38.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200013", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86146", "type": "HCPCS" } ], "description": "Hc Beta 2 Glycoprotein 1 Antibody Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.15, "gross_charge": 71.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200014", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86147", "type": "HCPCS" } ], "description": "Hc Cardiolipin Antibody Ea Ig Class", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200015", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86148", "type": "HCPCS" } ], "description": "Hc Anti Phosphatidylserine Ab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 381.55, "gross_charge": 587.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200016", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86157", "type": "HCPCS" } ], "description": "Hc Cold Agglutinin Titer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 52.0, "gross_charge": 80.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200017", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86160", "type": "HCPCS" } ], "description": "Hc Complement Antigen Each Component", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200019", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86162", "type": "HCPCS" } ], "description": "Hc Complement Ch50 Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 39.0, "gross_charge": 60.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200020", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86171", "type": "HCPCS" } ], "description": "Hc Complement Fixation Tests Ea Antigen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 143.65, "gross_charge": 221.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200021", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86200", "type": "HCPCS" } ], "description": "Hc Ccp Antibody", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.3, "gross_charge": 162.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200022", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86215", "type": "HCPCS" } ], "description": "Hc Dnase Antibody So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31.2, "gross_charge": 48.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200023", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86225", "type": "HCPCS" } ], "description": "Hc Dna Double Strand Antibody Dna Ds", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 154.7, "gross_charge": 238.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200024", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86226", "type": "HCPCS" } ], "description": "Hc Dna Antibody Single Stranded So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 304.85, "gross_charge": 469.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200025", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86235", "type": "HCPCS" } ], "description": "Hc Ena Antibody Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 223.6, "gross_charge": 344.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200026", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86255", "type": "HCPCS" } ], "description": "Hc Fluorescent Antibody Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 153.4, "gross_charge": 236.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200027", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86256", "type": "HCPCS" } ], "description": "Hc Fluorescent Antibody Titer So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 136.5, "gross_charge": 210.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200029", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86300", "type": "HCPCS" } ], "description": "Hc Ia For Tumor Antigen Quant Ca27.29", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200031", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86304", "type": "HCPCS" } ], "description": "Hc Ca 125 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25.35, "gross_charge": 39.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200032", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86305", "type": "HCPCS" } ], "description": "Hc Human Epididymis Protein 4 He4 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 73.45, "gross_charge": 113.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200033", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86308", "type": "HCPCS" } ], "description": "Hc Heterophile Antibodies Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 117.65, "gross_charge": 181.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200034", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86310", "type": "HCPCS" } ], "description": "Hc Heterophile Antibodies Titer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200036", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86317", "type": "HCPCS" } ], "description": "Hc Immunoassay Infect Agent Ab Quant Nos", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.95, "gross_charge": 223.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200041", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86331", "type": "HCPCS" } ], "description": "Hc Immunodiffusion Gel Dif Qual Ea Ag Antb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 93.6, "gross_charge": 144.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200042", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86332", "type": "HCPCS" } ], "description": "Hc Immune Complex Assay So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 156.0, "gross_charge": 240.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200043", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86334", "type": "HCPCS" } ], "description": "Hc Immunofixation Electrophoresis Serum Ife", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 208.0, "gross_charge": 320.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200044", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86335", "type": "HCPCS" } ], "description": "Hc Immunofixation Electrophoresis Other Fluid Ife So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200045", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86336", "type": "HCPCS" } ], "description": "Hc Inhibin A So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.7, "gross_charge": 78.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200046", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86337", "type": "HCPCS" } ], "description": "Hc Insulin Antibody So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 67.6, "gross_charge": 104.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200047", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86340", "type": "HCPCS" } ], "description": "Hc Intrinsic Factor Antibody So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.75, "gross_charge": 55.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200048", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86341", "type": "HCPCS" } ], "description": "Hc Islet Cell Antibody So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 54.6, "gross_charge": 84.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200050", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86352", "type": "HCPCS" } ], "description": "Hc Cell Fxn Assay Stim And Detect Biomrkr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 992.55, "gross_charge": 1527.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200051", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86353", "type": "HCPCS" } ], "description": "Hc Lymphocyte Mitogen Proliferation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 433.55, "gross_charge": 667.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200052", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86355", "type": "HCPCS" } ], "description": "Hc B Cells Total Count", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 377.0, "gross_charge": 580.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200053", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86356", "type": "HCPCS" } ], "description": "Hc Mononuclear Cell Ag Quant Nos Ea", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 179.4, "gross_charge": 276.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200054", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86357", "type": "HCPCS" } ], "description": "Hc Natural Killer Cells Total Ct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 376.35, "gross_charge": 579.0, "setting": "both" } ] }, { "code_information": [ { "code": "30200055", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86359", "type": "HCPCS" } ], 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37.7, "gross_charge": 58.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500014", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85048", "type": "HCPCS" } ], "description": "Hc Wbc Count Auto", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31.2, "gross_charge": 48.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500015", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85049", "type": "HCPCS" } ], "description": "Hc Platelet Count Auto", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500016", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85130", "type": "HCPCS" } ], "description": "Hc Chromogenic Substrate Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 78.0, "gross_charge": 120.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500018", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85210", "type": "HCPCS" } ], "description": "Hc Factor 2 Clotting Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1086.15, "gross_charge": 1671.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500019", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85220", "type": "HCPCS" } ], "description": "Hc Factor 5 Clotting Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 942.5, "gross_charge": 1450.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500020", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85230", "type": "HCPCS" } ], "description": "Hc Factor 7 Clotting Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 603.85, "gross_charge": 929.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500021", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85240", "type": "HCPCS" } ], "description": "Hc Factor 8 Clotting Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 874.25, "gross_charge": 1345.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500023", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85245", "type": "HCPCS" } ], "description": "Hc Ristocetin Cofactor So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.8, "gross_charge": 112.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500024", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85246", "type": "HCPCS" } ], "description": "Hc Factor 8 Vonwillebrand Antigen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.9, "gross_charge": 86.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500025", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85247", "type": "HCPCS" } ], "description": "Hc Factor 8 Vonwillebrand Multimetric So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 113.75, "gross_charge": 175.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500027", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85260", "type": "HCPCS" } ], "description": "Hc Factor 10 Clotting Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 902.85, "gross_charge": 1389.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500028", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85270", "type": "HCPCS" } ], "description": "Hc Factor 11 Clotting Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1043.9, "gross_charge": 1606.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500029", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85280", "type": "HCPCS" } ], "description": "Hc Factor 12 Clotting Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1086.15, "gross_charge": 1671.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500030", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85290", "type": "HCPCS" } ], "description": "Hc Factor 13 Fibrin Stabilizing So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 376.35, "gross_charge": 579.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500031", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85291", "type": "HCPCS" } ], "description": "Hc Factor 13 Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 921.7, "gross_charge": 1418.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500034", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85300", "type": "HCPCS" } ], "description": "Hc Antithrombin At3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 363.35, "gross_charge": 559.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500035", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85301", "type": "HCPCS" } ], "description": "Hc Antithrombin Iii Antigen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 68.9, "gross_charge": 106.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500036", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85302", "type": "HCPCS" } ], "description": "Hc Protein C Antigen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 151.45, "gross_charge": 233.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500037", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85303", "type": "HCPCS" } ], "description": "Hc Protein C Activity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 651.95, "gross_charge": 1003.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500038", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85305", "type": "HCPCS" } ], "description": "Hc Protein S Antigen Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.9, "gross_charge": 226.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500039", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85306", "type": "HCPCS" } ], "description": "Hc Protein S Antigen Free Total", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 520.0, "gross_charge": 800.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500040", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85307", "type": "HCPCS" } ], "description": "Hc Activated Protein C Resistance So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 110.5, "gross_charge": 170.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500041", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85335", "type": "HCPCS" } ], "description": "Hc Factor Inhibitor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 900.9, "gross_charge": 1386.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500043", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85347", "type": "HCPCS" } ], "description": "Hc Coag Time Activated Act", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 393.25, "gross_charge": 605.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500044", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85360", "type": "HCPCS" } ], "description": "Hc Euglobulin Lysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 45.5, "gross_charge": 70.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500046", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85379", "type": "HCPCS" } ], "description": "Hc D Dimer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500047", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85384", "type": "HCPCS" } ], "description": "Hc Fibrinogen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 40.3, "gross_charge": 62.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500048", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85385", "type": "HCPCS" } ], "description": "Hc Fibrinogen Antigen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500049", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85397", "type": "HCPCS" } ], "description": "Hc Clotting Functional Activity Nos Each So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 49.4, "gross_charge": 76.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500050", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85410", "type": "HCPCS" } ], "description": "Hc Alpha 2 Antiplasmin So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.25, "gross_charge": 165.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500051", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85415", "type": "HCPCS" } ], "description": "Hc Plasminogen Activator So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 308.1, "gross_charge": 474.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500052", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85420", "type": "HCPCS" } ], "description": "Hc Plasminogen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 540.8, "gross_charge": 832.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500053", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85441", "type": "HCPCS" } ], "description": "Hc Heinz Bodies Direct So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500054", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85460", "type": "HCPCS" } ], "description": "Hc Kleihauer-Betke Fetal Hemoglobin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1348.1, "gross_charge": 2074.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500055", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85461", "type": "HCPCS" } ], "description": "Hc Fetal Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 446.55, "gross_charge": 687.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500057", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85520", "type": "HCPCS" } ], "description": "Hc Heparin Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1079.65, "gross_charge": 1661.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500061", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85557", "type": "HCPCS" } ], "description": "Hc Rbc Osmotic Frag Incubated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 140.4, "gross_charge": 216.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500062", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85576", "type": "HCPCS" } ], "description": "Hc Platelet Aggregation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 384.8, "gross_charge": 592.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500063", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85597", "type": "HCPCS" } ], "description": "Hc Phospholipid Neutralization Platelet So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 321.1, "gross_charge": 494.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500064", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85598", "type": "HCPCS" } ], "description": "Hc Phospholipid Neutralization Hexagonal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 479.7, "gross_charge": 738.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500065", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85610", "type": "HCPCS" } ], "description": "Hc Pt/Inr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23.4, "gross_charge": 36.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500066", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85611", "type": "HCPCS" } ], "description": "Hc Pt Mixing Studies", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 886.6, "gross_charge": 1364.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500067", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85613", "type": "HCPCS" } ], "description": "Hc Dilute Russell Viper Venom Drvvt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 533.65, "gross_charge": 821.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500068", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85635", "type": "HCPCS" } ], "description": "Hc Reptilase Time So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500069", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85651", "type": "HCPCS" } ], "description": "Hc Sed Rate Esr Non Automated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 52.65, "gross_charge": 81.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500070", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85652", "type": "HCPCS" } ], "description": "Hc Sed Rate Esr Automated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.1, "gross_charge": 74.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500071", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85660", "type": "HCPCS" } ], "description": "Hc Sickle Cell Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 150.8, "gross_charge": 232.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500072", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85670", "type": "HCPCS" } ], "description": "Hc Thrombin Time Plasma", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500074", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85730", "type": "HCPCS" } ], "description": "Hc Aptt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500075", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85732", "type": "HCPCS" } ], "description": "Hc Ptt Mixing Studies", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 757.9, "gross_charge": 1166.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500077", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "G0328", "type": "HCPCS" } ], "description": "Hc Immunochemical Fecal Occult Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.95, "gross_charge": 83.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500081", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85018", "type": "HCPCS" } ], "description": "Hc Hemoglobin Wb Pulm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500085", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85245", "type": "HCPCS" } ], "description": "Hc Ristocetin Cofactor Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1903.85, "gross_charge": 2929.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500086", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85250", "type": "HCPCS" } ], "description": "Hc Factor 9 Assay", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 966.55, "gross_charge": 1487.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500090", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85397", "type": "HCPCS" } ], "description": "Hc Clotting Funct Activity Nos Ea", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 915.2, "gross_charge": 1408.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500107", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85014", "type": "HCPCS" } ], "description": "Hc Hematocrit Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500108", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85025", "type": "HCPCS" } ], "description": "Hc Cbc With Diff Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.15, "gross_charge": 31.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500114", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85335", "type": "HCPCS" } ], "description": "Hc Factor Inhibitor So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 609.05, "gross_charge": 937.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500119", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85598", "type": "HCPCS" } ], "description": "Hc Hexagonal Phospholipid Neutraliza So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 140.4, "gross_charge": 216.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500120", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85610", "type": "HCPCS" } ], "description": "Hc Pt Inr Amb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23.4, "gross_charge": 36.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500122", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "G0328", "type": "HCPCS" } ], "description": "Hc Immunochemical Fecal Occult Blood So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 118.95, "gross_charge": 183.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500123", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85014", "type": "HCPCS" } ], "description": "Hc Hematocrit Pulmonary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500127", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85549", "type": "HCPCS" } ], "description": "Hc Muramidase So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.9, "gross_charge": 66.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500128", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85810", "type": "HCPCS" } ], "description": "Hc Viscosity Serum So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.3, "gross_charge": 82.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500129", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85014", "type": "HCPCS" } ], "description": "Hc Fsed Hematocrit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500130", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85025", "type": "HCPCS" } ], "description": "Hc Fsed Cbc With Diff", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.15, "gross_charge": 31.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500131", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85379", "type": "HCPCS" } ], "description": "Hc Fsed D Dimer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500132", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85610", "type": "HCPCS" } ], "description": "Hc Fsed Pt/Inr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23.4, "gross_charge": 36.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500133", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85027", "type": "HCPCS" } ], "description": "Hc Fsed Cbc Without Diff", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18.2, "gross_charge": 28.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500134", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85660", "type": "HCPCS" } ], "description": "Hc Sickle Cell Screen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 64.35, "gross_charge": 99.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500137", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85130", "type": "HCPCS" } ], "description": "Hc Chromogenic Substrate Assay So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 557.7, "gross_charge": 858.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500138", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85610", "type": "HCPCS" } ], "description": "Hc Mstu Inr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23.4, "gross_charge": 36.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500139", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85014", "type": "HCPCS" } ], "description": "Hc Mstu Hematocrit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500140", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85018", "type": "HCPCS" } ], "description": "Hc Hemoglobin Wb Cath Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500141", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85018", "type": "HCPCS" } ], "description": "Hc Hemoglobin Wb Perfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500142", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85300", "type": "HCPCS" } ], "description": "Hc Antithrombin At3 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69.55, "gross_charge": 107.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500143", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85303", "type": "HCPCS" } ], "description": "Hc Protein C Activity So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.25, "gross_charge": 125.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500144", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85613", "type": "HCPCS" } ], "description": "Hc Dilute Russell Viper Venom Drvvt So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.9, "gross_charge": 86.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500145", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85397", "type": "HCPCS" } ], "description": "Hc Clotting Functional Activity Nos Each Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 259.35, "gross_charge": 399.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500146", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85246", "type": "HCPCS" } ], "description": "Hc Clotting Factor Viii Vw Factor Antigen Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1972.1, "gross_charge": 3034.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500147", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85292", "type": "HCPCS" } ], "description": "Hc Preallikrein Assay So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 406.25, "gross_charge": 625.0, "setting": "both" } ] }, { "code_information": [ { "code": "30500148", "type": "CDM" }, { "code": "305", "type": "RC" }, { "code": "85293", "type": "HCPCS" } ], "description": "Hc High Molecular Weight Kininogen Assay So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 406.25, "gross_charge": 625.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600001", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87015", "type": "HCPCS" } ], "description": "Hc Concentration Any Type For Inf Ag So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.9, "gross_charge": 206.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600002", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87040", "type": "HCPCS" } ], "description": "Hc Culture Blood Aerob Anaerob Pltlt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 93.6, "gross_charge": 144.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600003", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87045", "type": "HCPCS" } ], "description": "Hc Culture Stool Aerobic Ssyc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 235.3, "gross_charge": 362.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600004", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87046", "type": "HCPCS" } ], "description": "Hc Culture Stool Additional Pathogen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600005", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87070", "type": "HCPCS" } ], "description": "Hc Culture Aerobic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 193.05, "gross_charge": 297.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600006", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87071", "type": "HCPCS" } ], "description": "Hc Culture Bac Quantitative Aerobic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 261.95, "gross_charge": 403.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600007", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87015", "type": "HCPCS" } ], "description": "Hc Concentration Afb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.85, "gross_charge": 129.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600008", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87015", "type": "HCPCS" } ], "description": "Hc Malaria Thick Smear", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.85, "gross_charge": 129.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600010", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87040", "type": "HCPCS" } ], "description": "Hc Culture Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 157.95, "gross_charge": 243.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600045", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87075", "type": "HCPCS" } ], "description": "Hc Culture Anaerobic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 224.9, "gross_charge": 346.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600054", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87076", "type": "HCPCS" } ], "description": "Hc Culture Anaerobic Id", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 243.1, "gross_charge": 374.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600055", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87076", "type": "HCPCS" } ], "description": "Hc Organism Ref For Id Anaerobe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 74.1, "gross_charge": 114.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600058", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87077", "type": "HCPCS" } ], "description": "Hc Bacterial Identification", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.9, "gross_charge": 186.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600059", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87077", "type": "HCPCS" } ], "description": "Hc Organism Ref For Id Aerobe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.05, "gross_charge": 117.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600061", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87081", "type": "HCPCS" } ], "description": "Hc Culture Presumptive Path Org Scrn", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600066", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87081", "type": "HCPCS" } ], "description": "Hc Culture Presumptive Path Org Scrn So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 101.4, "gross_charge": 156.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600071", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87086", "type": "HCPCS" } ], "description": "Hc Culture Urine Aerobic Colony Count", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 135.85, "gross_charge": 209.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600072", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87088", "type": "HCPCS" } ], "description": "Hc Cult Urine Isol Presump Id Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 52.65, "gross_charge": 81.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600073", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87101", "type": "HCPCS" } ], "description": "Hc Culture Fungus Skin Hair Nails", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 377.65, "gross_charge": 581.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600074", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87102", "type": "HCPCS" } ], "description": "Hc Culture Fungus Not Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 307.45, "gross_charge": 473.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600089", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87103", "type": "HCPCS" } ], "description": "Hc Culture Blood Fungus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 319.15, "gross_charge": 491.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600090", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87106", "type": "HCPCS" } ], "description": "Hc Culture Fungus Id Yeast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 140.4, "gross_charge": 216.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600091", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87107", "type": "HCPCS" } ], "description": "Hc Fungi Identification Mold So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 95.55, "gross_charge": 147.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600092", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87109", "type": "HCPCS" } ], "description": "Hc Culture Mycoplasma So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 152.1, "gross_charge": 234.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600095", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87110", "type": "HCPCS" } ], "description": "Hc Culture Chlamydia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 250.25, "gross_charge": 385.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600096", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87116", "type": "HCPCS" } ], "description": "Hc Culture Afb Tb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 312.0, "gross_charge": 480.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600121", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87118", "type": "HCPCS" } ], "description": "Hc Culture Mycobacteria Id", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 234.65, "gross_charge": 361.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600122", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87140", "type": "HCPCS" } ], "description": "Hc Culture Type By Ifa Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 134.55, "gross_charge": 207.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600124", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87147", "type": "HCPCS" } ], "description": "Hc Culture Typing Serologic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 98.15, "gross_charge": 151.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600126", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87149", "type": "HCPCS" } ], "description": "Hc Culture Typing Nuc Acid Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 172.25, "gross_charge": 265.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600130", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87168", "type": "HCPCS" } ], "description": "Hc Arthropod Exam", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 118.95, "gross_charge": 183.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600131", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87169", "type": "HCPCS" } ], "description": "Hc Worm Exam", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.3, "gross_charge": 162.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600132", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87172", "type": "HCPCS" } ], "description": "Hc Pinworm Prep Rectum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 111.15, "gross_charge": 171.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600133", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87176", "type": "HCPCS" } ], "description": "Hc Homogenization Tissue For Culture", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 135.85, "gross_charge": 209.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600134", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87177", "type": "HCPCS" } ], "description": "Hc Ova & Parasite O And P Stool", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 300.3, "gross_charge": 462.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600135", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87181", "type": "HCPCS" } ], "description": "Hc Susceptibility Anaerobic Mic So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.3, "gross_charge": 102.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600137", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87181", "type": "HCPCS" } ], "description": "Hc Susceptibility Study E Test", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600140", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87185", "type": "HCPCS" } ], "description": "Hc Susceptibility Study Enzyme Det", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600142", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87186", "type": "HCPCS" } ], "description": "Hc Sensitivity Mic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 103.35, "gross_charge": 159.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600143", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87186", "type": "HCPCS" } ], "description": "Hc Susceptibility Aerobic Mic So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 226.2, "gross_charge": 348.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600148", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87188", "type": "HCPCS" } ], "description": "Hc Susceptibility Mtb Complex So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 406.25, "gross_charge": 625.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600152", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87205", "type": "HCPCS" } ], "description": "Hc Gram Stain Smear Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.3, "gross_charge": 162.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600153", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87206", "type": "HCPCS" } ], "description": "Hc Smear Fluorescent Acid Stain", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600159", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87207", "type": "HCPCS" } ], "description": "Hc Smear Spec Stain Bodies Parasites", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.9, "gross_charge": 186.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600161", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87207", "type": "HCPCS" } ], "description": "Hc Stain For Inclusion Bodies Parasites So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 417.95, "gross_charge": 643.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600162", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87209", "type": "HCPCS" } ], "description": "Hc Smr Prim Src Cplx Spec Stain So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 134.55, "gross_charge": 207.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600163", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87209", "type": "HCPCS" } ], "description": "Hc Trichrome Stain", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 191.1, "gross_charge": 294.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600165", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87210", "type": "HCPCS" } ], "description": "Hc Smear Wet Preparation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.7, "gross_charge": 198.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600169", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87253", "type": "HCPCS" } ], "description": "Hc T Culture Addl Studies By Ifa", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 135.85, "gross_charge": 209.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600170", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87252", "type": "HCPCS" } ], "description": "Hc Culture Viral Comprehensive So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37.05, "gross_charge": 57.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600172", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87254", "type": "HCPCS" } ], "description": "Hc Virus Isol Shell Vial Ea", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 39.0, "gross_charge": 60.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600173", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87255", "type": "HCPCS" } ], "description": "Hc Culture Viral Hsv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 231.4, "gross_charge": 356.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600174", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87260", "type": "HCPCS" } ], "description": "Hc Adenovirus Antigen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 90.35, "gross_charge": 139.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600177", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87278", "type": "HCPCS" } ], "description": "Hc Legionella Dfa", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.7, "gross_charge": 178.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600179", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87280", "type": "HCPCS" } ], "description": "Hc Rsv Antigen Dfa", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 226.85, "gross_charge": 349.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600180", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87281", "type": "HCPCS" } ], "description": "Hc Pneumocystis Dfa Bronchial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 250.9, "gross_charge": 386.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600184", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87420", "type": "HCPCS" } ], "description": "Hc Rsv Antigen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 68.9, "gross_charge": 106.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600187", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87471", "type": "HCPCS" } ], "description": "Hc Bartonella By Pcr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 179.4, "gross_charge": 276.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600189", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87476", "type": "HCPCS" } ], "description": "Hc Lyme Disease By Pcr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 160.55, "gross_charge": 247.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600190", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87480", "type": "HCPCS" } ], "description": "Hc Candida Species Direct Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.95, "gross_charge": 163.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600191", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87486", "type": "HCPCS" } ], "description": "Hc Chlamydia Pneumoniae Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 618.8, "gross_charge": 952.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600192", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87490", "type": "HCPCS" } ], "description": "Hc Dna Probe Chlamydia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37.05, "gross_charge": 57.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600196", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87491", "type": "HCPCS" } ], "description": "Hc Rna Probe Amplified Chlamydia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.15, "gross_charge": 91.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600197", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87493", "type": "HCPCS" } ], "description": "Hc C Difficile Toxin Gene Pcr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 148.85, "gross_charge": 229.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600198", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87493", "type": "HCPCS" } ], "description": "Hc C Difficile Toxin Pcr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 148.85, "gross_charge": 229.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600199", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87496", "type": "HCPCS" } ], "description": "Hc Cmv Amplified Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 117.0, "gross_charge": 180.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600200", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87497", "type": "HCPCS" } ], "description": "Hc Cmv By Pcr Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.9, "gross_charge": 186.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600205", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87502", "type": "HCPCS" } ], "description": "Hc Influenza Rna Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.85, "gross_charge": 409.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600206", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87503", "type": "HCPCS" } ], "description": "Hc Influenza Dna Amp Probe Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 64.35, "gross_charge": 99.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600207", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87510", "type": "HCPCS" } ], "description": "Hc Gardnerella Vaginalis Direct Prob", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.95, "gross_charge": 163.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600209", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87517", "type": "HCPCS" } ], "description": "Hc Hepatitis B Viral Dna So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 165.75, "gross_charge": 255.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600214", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87522", "type": "HCPCS" } ], "description": "Hc Hcv Virus Quantitation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 819.65, "gross_charge": 1261.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600220", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87530", "type": "HCPCS" } ], "description": "Hc Herpes Simplex Virus By Pcr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.85, "gross_charge": 409.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600221", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87532", "type": "HCPCS" } ], "description": "Hc Human Herpes Virus-6 Hhv 6 Pcr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.25, "gross_charge": 225.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600222", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87535", "type": "HCPCS" } ], "description": "Hc Hiv Amplified Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 122.85, "gross_charge": 189.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600223", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87536", "type": "HCPCS" } ], "description": "Hc Hiv-1 Quant And Reverse Transcription So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 165.75, "gross_charge": 255.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600224", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87536", "type": "HCPCS" } ], "description": "Hc Hiv 1 Virus Quantitation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 725.4, "gross_charge": 1116.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600225", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87538", "type": "HCPCS" } ], "description": "Hc Hiv 2 Amplified Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 390.65, "gross_charge": 601.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600226", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87556", "type": "HCPCS" } ], "description": "Hc Tuberculosis By Pcr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 282.75, "gross_charge": 435.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600227", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87581", "type": "HCPCS" } ], "description": "Hc Mycoplasma Pneumoniae By Pcr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 310.05, "gross_charge": 477.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600228", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87590", "type": "HCPCS" } ], "description": "Hc Dna Probe Gonorrhoeae Gc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 186.55, "gross_charge": 287.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600230", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87591", "type": "HCPCS" } ], "description": "Hc Rna Probe Amplified Gonorrhoeae", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.15, "gross_charge": 91.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600232", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87625", "type": "HCPCS" } ], "description": "Hc Hpv Types 16 And 18 Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 65.65, "gross_charge": 101.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600235", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87641", "type": "HCPCS" } ], "description": "Hc Mrsa Screen Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 407.55, "gross_charge": 627.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600236", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87650", "type": "HCPCS" } ], "description": "Hc Streptococcus Grp A Direct Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 215.8, "gross_charge": 332.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600238", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87660", "type": "HCPCS" } ], "description": "Hc Trichomonas Vaginalis Direct Prob", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.95, "gross_charge": 163.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600243", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87798", "type": "HCPCS" } ], "description": "Hc Infectious Agent Det Amplified Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 513.5, "gross_charge": 790.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600248", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87798", "type": "HCPCS" } ], "description": "Hc Infectious Agent Det Amplified Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 300.95, "gross_charge": 463.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600257", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87799", "type": "HCPCS" } ], "description": "Hc Infectious Agent Quant Dir Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 208.0, "gross_charge": 320.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600259", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87801", "type": "HCPCS" } ], "description": "Hc Dna/Rna; Multi Org-Amp Pr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 193.7, "gross_charge": 298.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600262", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87880", "type": "HCPCS" } ], "description": "Hc Rapid Strep Antigen Grp A Throat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.2, "gross_charge": 88.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600268", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87900", "type": "HCPCS" } ], "description": "Hc Inf Agnt Drg Sscep Phen Pred Bioi So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 493.35, "gross_charge": 759.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600269", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87901", "type": "HCPCS" } ], "description": "Hc Genotype Hiv Reverse T So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 973.05, "gross_charge": 1497.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600271", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87903", "type": "HCPCS" } ], "description": "Hc Infct Phentyp Resist Tiss Cul Hiv 1St 1 To 10 Drugs So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1845.35, "gross_charge": 2839.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600272", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87904", "type": "HCPCS" } ], "description": "Hc Infct Phentyp Resist Tiss Cul Hiv Ea Addl Drug So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 98.15, "gross_charge": 151.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600276", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87556", "type": "HCPCS" } ], "description": "Hc M Tuberculosis Amplified Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 352.95, "gross_charge": 543.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600277", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87631", "type": "HCPCS" } ], "description": "Hc Resp Virus 3 To 5 Targets", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 348.4, "gross_charge": 536.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600278", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87906", "type": "HCPCS" } ], "description": "Hc Genotype Dna Or Rna Hiv So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 863.2, "gross_charge": 1328.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600279", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87498", "type": "HCPCS" } ], "description": "Hc Enterovirus By Pcr Amplified Prob So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 78.65, "gross_charge": 121.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600280", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87502", "type": "HCPCS" } ], "description": "Hc Influenza Dna Or Rna Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.85, "gross_charge": 409.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600283", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87653", "type": "HCPCS" } ], "description": "Hc Strep Group B By Pcr Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 231.4, "gross_charge": 356.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600286", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87899", "type": "HCPCS" } ], "description": "Hc Inf Agnt Det Optical Obs Nos", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 151.45, "gross_charge": 233.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600289", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87305", "type": "HCPCS" } ], "description": "Hc Aspergillus Antigen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 97.5, "gross_charge": 150.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600290", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87529", "type": "HCPCS" } ], "description": "Hc Hsv By Pcr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.15, "gross_charge": 131.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600291", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87624", "type": "HCPCS" } ], "description": "Hc Hpv Probe High Risk Types So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 112.45, "gross_charge": 173.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600293", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87801", "type": "HCPCS" } ], "description": "Hc Inf Agt Det By Nuc Acid Amp Pr So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 243.1, "gross_charge": 374.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600294", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87661", "type": "HCPCS" } ], "description": "Hc Trichomonas Vaginalis Amplif So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 97.5, "gross_charge": 150.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600295", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87185", "type": "HCPCS" } ], "description": "Hc Susceptibility Study Enzyme Det So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.7, "gross_charge": 78.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600296", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87186", "type": "HCPCS" } ], "description": "Hc Susceptibility Mic Each Per Plate So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 326.95, "gross_charge": 503.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600297", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87491", "type": "HCPCS" } ], "description": "Hc Chlamydia Trachomatis Amplified Rna So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.15, "gross_charge": 91.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600298", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87591", "type": "HCPCS" } ], "description": "Hc Neisseria Gonnorrhoeae Amplified Rna So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.15, "gross_charge": 91.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600299", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87632", "type": "HCPCS" } ], "description": "Hc Resp Virus 6 To 11 Targets So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 304.2, "gross_charge": 468.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600300", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87902", "type": "HCPCS" } ], "description": "Hc Hcv Viral Rna Drug Resistance So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 251.55, "gross_charge": 387.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600301", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87150", "type": "HCPCS" } ], "description": "Hc Culture Typing Nuc Acid Probe Amp Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.7, "gross_charge": 98.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600302", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87798", "type": "HCPCS" } ], "description": "Hc Infectious Agent Det Amp Probe Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69.55, "gross_charge": 107.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600303", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87653", "type": "HCPCS" } ], "description": "Hc Strep Group B Amp Probe Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 231.4, "gross_charge": 356.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600304", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87496", "type": "HCPCS" } ], "description": "Hc Cmv Amp Probe Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600305", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87498", "type": "HCPCS" } ], "description": "Hc Enterovirus Amp Probe Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69.55, "gross_charge": 107.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600306", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87532", "type": "HCPCS" } ], "description": "Hc Human Herpes Virus-6 Amp Probe Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69.55, "gross_charge": 107.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600307", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87529", "type": "HCPCS" } ], "description": "Hc Hsv Amp Probe Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69.55, "gross_charge": 107.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600308", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "87507", "type": "HCPCS" } ], "description": "Hc Iadna-Dna/Rna Gi Pthgn Multiplex Probe Tq 12-25", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 860.6, "gross_charge": 1324.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600309", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87633", "type": "HCPCS" } ], "description": "Hc Iadna Respiratry Probe & Rev Trnscr 12-25 Target", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 611.0, "gross_charge": 940.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600310", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87486", "type": "HCPCS" } ], "description": "Hc Chylmd Pneum Dna Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600311", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87581", "type": "HCPCS" } ], "description": "Hc Myco Pneumon Dna Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 38.35, "gross_charge": 59.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600312", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87661", "type": "HCPCS" } ], "description": "Hc Trichomonas Vaginalis Amplified Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 62.4, "gross_charge": 96.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600313", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "87507", "type": "HCPCS" } ], "description": "Hc Iadna-Dna/Rna Gi Pthgn Multiplex Probe Tq 12-25 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 585.0, "gross_charge": 900.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600314", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87483", "type": "HCPCS" } ], "description": "Hc Cns Dna Amp Probe Type 12-25", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 988.0, "gross_charge": 1520.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600315", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87505", "type": "HCPCS" } ], "description": "Hc Nfct Agent Dna/Rna Gastrointestinal Pathogen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 148.2, "gross_charge": 228.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600316", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87502", "type": "HCPCS" } ], "description": "Hc Fsed Influenza Dna Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.85, "gross_charge": 409.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600317", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87807", "type": "HCPCS" } ], "description": "Hc Fsed Rsv Antigen Nasal Swab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 354.25, "gross_charge": 545.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600318", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87808", "type": "HCPCS" } ], "description": "Hc Fsed Trichomonas", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20.8, "gross_charge": 32.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600319", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87880", "type": "HCPCS" } ], "description": "Hc Fsed Rapid Strep Antigen Grp A Throat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.2, "gross_charge": 88.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600320", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87912", "type": "HCPCS" } ], "description": "Hc Genotype Dna Hepatitis B So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 926.25, "gross_charge": 1425.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600321", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87177", "type": "HCPCS" } ], "description": "Hc Ova And Parasites Smears So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600322", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87481", "type": "HCPCS" } ], "description": "Hc Iadna Candida Species Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 109.2, "gross_charge": 168.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600323", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87899", "type": "HCPCS" } ], "description": "Hc Inf Agnt Det Optical Obs Nos Rapid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22.1, "gross_charge": 34.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600324", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87207", "type": "HCPCS" } ], "description": "Hc Smear Spec Stain Bodies Parasites Blood", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 143.0, "gross_charge": 220.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600328", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87533", "type": "HCPCS" } ], "description": "Hc Iadna Herpes Virus 6 Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1324.7, "gross_charge": 2038.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600329", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87210", "type": "HCPCS" } ], "description": "Hc Smear Wet Preparation So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 192.4, "gross_charge": 296.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600330", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87150", "type": "HCPCS" } ], "description": "Hc Cultyp Nuc Acid Amp Prb Cult/Isolate Ea Orgnism So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 153.4, "gross_charge": 236.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600331", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87651", "type": "HCPCS" } ], "description": "Hc Streptococcus Group A Amplified Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600332", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87102", "type": "HCPCS" } ], "description": "Hc Culture Fungus Not Blood So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600333", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87046", "type": "HCPCS" } ], "description": "Hc Culture Stool Additional Pathogen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 78.0, "gross_charge": 120.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600334", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87045", "type": "HCPCS" } ], "description": "Hc Culture Stool Aerobic Ssyc So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600335", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87651", "type": "HCPCS" } ], "description": "Hc Strep A Amplif Na Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600336", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87634", "type": "HCPCS" } ], "description": "Hc Rsv Dna/Rna Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600337", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87522", "type": "HCPCS" } ], "description": "Hc Hepatitis C Quant And Reverse Transcription So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 175.5, "gross_charge": 270.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600338", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87636", "type": "HCPCS" } ], "description": "Hc Sarscov2 And Flu A/B Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 230.75, "gross_charge": 355.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600339", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87637", "type": "HCPCS" } ], "description": "Hc Sarscov2 And Flu A/B And Rsv Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 230.75, "gross_charge": 355.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600340", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87801", "type": "HCPCS" } ], "description": "Hc Inf Agt Det By Nuc Acid Amp Pr Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 715.0, "gross_charge": 1100.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600341", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87636", "type": "HCPCS" } ], "description": "Hc Sars-Cov2 And Flu A/B Amp Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 230.75, "gross_charge": 355.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600342", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87636", "type": "HCPCS" } ], "description": "Hc Sars-Cov2 And Flu A/B Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 278.85, "gross_charge": 429.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600343", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87651", "type": "HCPCS" } ], "description": "Hc Fsed Strep Group A Amplified Probe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600344", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87640", "type": "HCPCS" } ], "description": "Hc Staph Aureus Dna Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 308.1, "gross_charge": 474.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600345", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87798", "type": "HCPCS" } ], "description": "Hc Amplif Na Probe Nos Agent So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 82.55, "gross_charge": 127.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600346", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87551", "type": "HCPCS" } ], "description": "Hc Mycobacteria Dna Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 635.05, "gross_charge": 977.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600349", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87506", "type": "HCPCS" } ], "description": "Hc Iadna-Dna/Rna Gi Pthgn Multiplex Probe Tq 6-11", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 860.6, "gross_charge": 1324.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600350", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87493", "type": "HCPCS" } ], "description": "Hc C Diff Amplified Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.05, "gross_charge": 177.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600351", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "81431", "type": "HCPCS" } ], "description": "Hc Hearing Loss Dup/Del Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1602.9, "gross_charge": 2466.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600352", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87040", "type": "HCPCS" } ], "description": "Hc Bacterial Culture, Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 93.6, "gross_charge": 144.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600353", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87070", "type": "HCPCS" } ], "description": "Hc Donor Culture Bacterial Aerobic (Excp Urn Bld Stool), Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 56.55, "gross_charge": 87.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600354", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87077", "type": "HCPCS" } ], "description": "Hc Aerobic Definitive Identification Each, Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37.7, "gross_charge": 58.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600355", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87147", "type": "HCPCS" } ], "description": "Hc Donor Immunologic Serotyping Each, Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600356", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87150", "type": "HCPCS" } ], "description": "Hc Cultyp Nuc Acid Amp Prb Cult/Isolate Ea Organism, Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.7, "gross_charge": 98.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600357", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87181", "type": "HCPCS" } ], "description": "Hc Microbe Susceptibility E-Test Each, Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600358", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87185", "type": "HCPCS" } ], "description": "Hc Microbe Enzyme Detection Each, Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 35.1, "gross_charge": 54.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600359", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87186", "type": "HCPCS" } ], "description": "Hc Microbe Suseptibility Mic Each, Cell Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600360", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87799", "type": "HCPCS" } ], "description": "Hc Infectious Agent Quant Dir Probe Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 614.9, "gross_charge": 946.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600361", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87593", "type": "HCPCS" } ], "description": "Hc Inf Agt Det; Orthopoxvirus (Monkeypox, Cowpox, Vaccinia) By Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 187.2, "gross_charge": 288.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600362", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87230", "type": "HCPCS" } ], "description": "Hc Toxin Or Antitoxin Assay Tissue Culture So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.85, "gross_charge": 129.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600363", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87467", "type": "HCPCS" } ], "description": "Hc Hepatitis B Surface Antigen, Quant So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 488.15, "gross_charge": 751.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600364", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87468", "type": "HCPCS" } ], "description": "Hc Infect Agent Detect Nuc Acid (Dnr/Rna); Anaplasma Phagocytophilim, Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600365", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87469", "type": "HCPCS" } ], "description": "Hc Infect Agent Detect Nuc Acid (Dnr/Rna); Babesia Microti, Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.25, "gross_charge": 165.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600366", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87478", "type": "HCPCS" } ], "description": "Hc Infect Agent Detect Nuc Acid (Dnr/Rna); Borrelia Miyamotoi, Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 843.7, "gross_charge": 1298.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600367", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87484", "type": "HCPCS" } ], "description": "Hc Infect Agent Detect Nuc Acid (Dnr/Rna); Ehrlichia Chaffeensis, Amp Probe So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 33.15, "gross_charge": 51.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600368", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87910", "type": "HCPCS" } ], "description": "Hc Nfct Agt Genotype Alys Nucleic Acid Cmv So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1326.0, "gross_charge": 2040.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600369", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "85306", "type": "HCPCS" } ], "description": "Hc Protein S Antigen Free Total So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 89.7, "gross_charge": 138.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600370", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87118", "type": "HCPCS" } ], "description": "Hc Culture Mycobacteria Id So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 117.65, "gross_charge": 181.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600371", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87076", "type": "HCPCS" } ], "description": "Hc Organism Ref For Id Anaerobe Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 195.0, "gross_charge": 300.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600372", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87493", "type": "HCPCS" } ], "description": "Hc C Difficille Toxin Pcr, Fecal So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1120.6, "gross_charge": 1724.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600373", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87635", "type": "HCPCS" } ], "description": "Hc Sars-Cov-2 Covid-19 Amp Prb High Troughput Method St", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 168.35, "gross_charge": 259.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600374", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87635", "type": "HCPCS" } ], "description": "Hc Sars-Cov-2 Covid-19 Amp Prb High Troughput Method So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 168.35, "gross_charge": 259.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600375", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87635", "type": "HCPCS" } ], "description": "Hc Sars-Cov-2 Covid-19 Amp Prb High Troughput Method Mb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 168.35, "gross_charge": 259.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600377", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87999", "type": "HCPCS" } ], "description": "Hc Biofire Joint Panel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 487.5, "gross_charge": 750.0, "setting": "both" } ] }, { "code_information": [ { "code": "30600378", "type": "CDM" }, { "code": "306", "type": "RC" }, { "code": "87801", "type": "HCPCS" } ], "description": "Hc Inf Agt Det By Nuc Acid Amp Pr Metagenomic Ngs So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5850.0, "gross_charge": 9000.0, "setting": "both" } ] }, { "code_information": [ 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"31000181", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "0431U", "type": "HCPCS" } ], "description": "Hc Glycine Alpha 1 Igg Srm/Csf So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1228.5, "gross_charge": 1890.0, "setting": "both" } ] }, { "code_information": [ { "code": "31000182", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "0432U", "type": "HCPCS" } ], "description": "Hc Klhl11 Antb Sr/Csf Assay Qual So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1170.0, "gross_charge": 1800.0, "setting": "both" } ] }, { "code_information": [ { "code": "31000183", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "0430U", "type": "HCPCS" } ], "description": "Hc Malabsorption Eval Panel So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1638.0, "gross_charge": 2520.0, "setting": "both" } ] }, { "code_information": [ { "code": "31000184", "type": "CDM" }, { "code": "310", "type": "RC" }, { "code": "81463", "type": "HCPCS" } ], "description": "Hc Gsap Sol Org Neo Cell Free Nuc Acid Dna Anal Cpy Numbr & Mcrstl Instab So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7020.0, "gross_charge": 10800.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100001", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88142", "type": "HCPCS" } ], "description": "Hc Cytopath Pap Smear Thin", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 44.85, "gross_charge": 69.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100002", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "G0145", "type": "HCPCS" } ], "description": "Hc Cyto Pap Smear Automated Mcare", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.15, "gross_charge": 131.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100006", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88172", "type": "HCPCS" } ], "description": "Hc Fine Needle Aspiration Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 278.2, "gross_charge": 428.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100007", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88173", "type": "HCPCS" } ], "description": "Hc Fine Needle Aspiration Interp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 733.2, "gross_charge": 1128.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100008", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88175", "type": "HCPCS" } ], "description": "Hc Cyto Pap Smear Automated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.7, "gross_charge": 78.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100009", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88177", "type": "HCPCS" } ], "description": "Hc Fna Immed Each Eval Same Site", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 239.85, "gross_charge": 369.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100010", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88182", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Cell Cycle Dna", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 108.55, "gross_charge": 167.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100013", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88184", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Initial Marker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 200.85, "gross_charge": 309.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100014", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88184", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Initial Marker So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 222.95, "gross_charge": 343.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100016", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88185", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Marker Tc Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100022", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88185", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Marker Tc Ea Addl So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 104.65, "gross_charge": 161.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100023", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88182", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Cell Cycle Dna Analysis So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 755.95, "gross_charge": 1163.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100024", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88271", "type": "HCPCS" } ], "description": "Hc Mol Cyto Dna Fish Probe Ea Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 459.55, "gross_charge": 707.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100025", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88275", "type": "HCPCS" } ], "description": "Hc Mol Cyto In Situ 100 To 300 Cells Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 621.4, "gross_charge": 956.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100026", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88184", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Initial Marker Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 213.2, "gross_charge": 328.0, "setting": "both" } ] }, { "code_information": [ { "code": "31100027", "type": "CDM" }, { "code": "311", "type": "RC" }, { "code": "88185", "type": "HCPCS" } ], "description": "Hc Flow Cytometry Marker Tc Ea Addl Special So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 213.2, "gross_charge": 328.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000003", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70030", "type": "HCPCS" } ], "description": "Hc Xr Eye For Foreign Body", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 178.75, "gross_charge": 275.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000003_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70030", "type": "HCPCS" } ], "description": "Hc Xr Eye For Foreign Body", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 357.5, "gross_charge": 550.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000004", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70100", "type": "HCPCS" } ], "description": "Hc Mandible Partial Less Than 4 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 138.45, "gross_charge": 213.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000005", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70110", "type": "HCPCS" } ], "description": "Hc Xr Mandible Complete 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 235.95, "gross_charge": 363.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000006", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70130", "type": "HCPCS" } ], "description": "Hc Xr Mastoids Complete 3 + Vw Per Side", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 322.4, "gross_charge": 496.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000006_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70130", "type": "HCPCS" } ], "description": "Hc Xr Mastoids Complete 3 + Vw Per Side", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 644.8, "gross_charge": 992.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000007", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70134", "type": "HCPCS" } ], "description": "Hc Xr Internal Auditory Meati Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1223.95, "gross_charge": 1883.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000008", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70140", "type": "HCPCS" } ], "description": "Hc Xr Facial Bones Less Than 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.9, "gross_charge": 206.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000009", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70150", "type": "HCPCS" } ], "description": "Hc Xr Facial Bones Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 252.2, "gross_charge": 388.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000010", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70160", "type": "HCPCS" } ], "description": "Hc Xr Nasal Bones Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 154.7, "gross_charge": 238.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000011", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70190", "type": "HCPCS" } ], "description": "Hc Xr Optic Foramina", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 246.35, "gross_charge": 379.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000011_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70190", "type": "HCPCS" } ], "description": "Hc Xr Optic Foramina", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 492.7, "gross_charge": 758.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000012", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70200", "type": "HCPCS" } ], "description": "Hc Xr Orbits Complete 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 278.2, "gross_charge": 428.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000013", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70210", "type": "HCPCS" } ], "description": "Hc Xr Sinuses Paranasal Less Than 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.3, "gross_charge": 222.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000014", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70220", "type": "HCPCS" } ], "description": "Hc Xr Sinuses Paranasal Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 258.7, "gross_charge": 398.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000015", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70240", "type": "HCPCS" } ], "description": "Hc Xr Sella Turcica", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 177.45, "gross_charge": 273.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000016", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70250", "type": "HCPCS" } ], "description": "Hc Xr Skull Less Than 4 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 233.35, "gross_charge": 359.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000017", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70260", "type": "HCPCS" } ], "description": "Hc Xr Skull Complete 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 337.35, "gross_charge": 519.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000018", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70328", "type": "HCPCS" } ], "description": "Hc Xr Tmj Open And Closed Mouth Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 147.55, "gross_charge": 227.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000019", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70330", "type": "HCPCS" } ], "description": "Hc Xr Tmj Open And Closed Mouth Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 242.45, "gross_charge": 373.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000022", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70355", "type": "HCPCS" } ], "description": "Hc Orthopantogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 170.3, "gross_charge": 262.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000023", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70360", "type": "HCPCS" } ], "description": "Hc Xr Neck Soft Tissue", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 202.8, "gross_charge": 312.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000027", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "70390", "type": "HCPCS" } ], "description": "Hc Xr Sialogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 478.4, "gross_charge": 736.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000028", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "71100", "type": "HCPCS" } ], "description": "Hc Xr Ribs Unilateral 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 209.3, "gross_charge": 322.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000029", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "71101", "type": "HCPCS" } ], "description": "Hc Xr Ribs Unilateral W Cxr 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 328.25, "gross_charge": 505.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000030", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "71110", "type": "HCPCS" } ], "description": "Hc Xr Ribs Bilateral 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 354.25, "gross_charge": 545.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000031", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "71111", "type": "HCPCS" } ], "description": "Hc Xr Ribs Bilateral W Cxr 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 419.25, "gross_charge": 645.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000032", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "71120", "type": "HCPCS" } ], "description": "Hc Xr Sternum 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 195.0, "gross_charge": 300.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000033", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "71130", "type": "HCPCS" } ], "description": "Hc Xr Sternoclavicular Joints 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 230.75, "gross_charge": 355.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000034", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72020", "type": "HCPCS" } ], "description": "Hc Xr Spine 1 Vw Specify Level", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 204.75, "gross_charge": 315.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000035", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72040", "type": "HCPCS" } ], "description": "Hc Xr Cervical Spine 2 To 3 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 235.95, "gross_charge": 363.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000036", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72050", "type": "HCPCS" } ], "description": "Hc Xr Cervical Spine 4 To 5 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 299.65, "gross_charge": 461.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000037", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72052", "type": "HCPCS" } ], "description": "Hc Xr Cervical Spine 6 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 360.75, "gross_charge": 555.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000039", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72070", "type": "HCPCS" } ], "description": "Hc Xr Thoracic Spine 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 216.45, "gross_charge": 333.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000040", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72072", "type": "HCPCS" } ], "description": "Hc Xr Thoracic Spine 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 258.7, "gross_charge": 398.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000041", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72074", "type": "HCPCS" } ], "description": "Hc Xr Thoracic Spine 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 321.1, "gross_charge": 494.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000042", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72080", "type": "HCPCS" } ], "description": "Hc Xr Thoracolumbar Spine 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 204.75, "gross_charge": 315.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000044", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72100", "type": "HCPCS" } ], "description": "Hc Xr Lumbosacral Spine 2 Or 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.7, "gross_charge": 318.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000045", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72110", "type": "HCPCS" } ], "description": "Hc Xr Lumbosacral Spine 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 286.65, "gross_charge": 441.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000046", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72114", "type": "HCPCS" } ], "description": "Hc Xr Lumbosacral Spine Complete W Bend 6 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 366.6, "gross_charge": 564.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000047", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72120", "type": "HCPCS" } ], "description": "Hc Xr Lumbosacral Spine Bending Only 2 Or 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.7, "gross_charge": 318.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000048", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72170", "type": "HCPCS" } ], "description": "Hc Xr Pelvis 1 Or 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 234.65, "gross_charge": 361.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000049", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72190", "type": "HCPCS" } ], "description": "Hc Xr Pelvis Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 300.95, "gross_charge": 463.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000050", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72200", "type": "HCPCS" } ], "description": "Hc Xr Sacroiliac Joints Less Than 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 173.55, "gross_charge": 267.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000051", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72202", "type": "HCPCS" } ], "description": "Hc Xr Sacroiliac Joints 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 235.3, "gross_charge": 362.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000052", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72220", "type": "HCPCS" } ], "description": "Hc Xr Sacrum/Coccyx 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 223.6, "gross_charge": 344.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000053", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72240", "type": "HCPCS" } ], "description": "Hc Myelogram Cervical", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 921.05, "gross_charge": 1417.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000054", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72255", "type": "HCPCS" } ], "description": "Hc Myelogram Thoracic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 950.3, "gross_charge": 1462.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000055", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72265", "type": "HCPCS" } ], "description": "Hc Myelogram Lumbosacral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 970.45, "gross_charge": 1493.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000056", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72270", "type": "HCPCS" } ], "description": "Hc Myelogram 2 Or More Regions", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1181.05, "gross_charge": 1817.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000058", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72285", "type": "HCPCS" } ], "description": "Hc Discogram Cervical Or Thoracic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2646.15, "gross_charge": 4071.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000060", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72295", "type": "HCPCS" } ], "description": "Hc Discogram Lumbar", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1907.1, "gross_charge": 2934.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000061", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73000", "type": "HCPCS" } ], "description": "Hc Xr Clavicle Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 193.05, "gross_charge": 297.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000061_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73000", "type": "HCPCS" } ], "description": "Hc Xr Clavicle Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 386.1, "gross_charge": 594.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000062", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73010", "type": "HCPCS" } ], "description": "Hc Xr Scapula Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 223.6, "gross_charge": 344.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000062_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73010", "type": "HCPCS" } ], "description": "Hc Xr Scapula Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 447.2, "gross_charge": 688.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000063", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73020", "type": "HCPCS" } ], "description": "Hc Xr Shoulder 1 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 192.4, "gross_charge": 296.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000063_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73020", "type": "HCPCS" } ], "description": "Hc Xr Shoulder 1 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 384.8, "gross_charge": 592.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000064", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73030", "type": "HCPCS" } ], "description": "Hc Xr Shoulder Complete 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 287.95, "gross_charge": 443.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000064_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73030", "type": "HCPCS" } ], "description": "Hc Xr Shoulder Complete 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 575.9, "gross_charge": 886.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000065", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73040", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Shoulder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 529.75, "gross_charge": 815.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000065_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73040", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Shoulder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1059.5, "gross_charge": 1630.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000066", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73050", "type": "HCPCS" } ], "description": "Hc Xr Ac Joints Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 215.15, "gross_charge": 331.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000067", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73060", "type": "HCPCS" } ], "description": "Hc Xr Humerus 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 217.75, "gross_charge": 335.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000068", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73070", "type": "HCPCS" } ], "description": "Hc Xr Elbow 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 204.75, "gross_charge": 315.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000068_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73070", "type": "HCPCS" } ], "description": "Hc Xr Elbow 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 409.5, "gross_charge": 630.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000069", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73080", "type": "HCPCS" } ], "description": "Hc Xr Elbow Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 240.5, "gross_charge": 370.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000069_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73080", "type": "HCPCS" } ], "description": "Hc Xr Elbow Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 481.0, "gross_charge": 740.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000070", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73085", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Elbow", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 658.45, "gross_charge": 1013.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000070_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73085", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Elbow", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1316.9, "gross_charge": 2026.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000071", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73090", "type": "HCPCS" } ], "description": "Hc Xr Forearm 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 215.8, "gross_charge": 332.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000071_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73090", "type": "HCPCS" } ], "description": "Hc Xr Forearm 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 431.6, "gross_charge": 664.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000072", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73092", "type": "HCPCS" } ], "description": "Hc Xr Upper Extremity Infant 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 246.35, "gross_charge": 379.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000072_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73092", "type": "HCPCS" } ], "description": "Hc Xr Upper Extremity Infant 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 492.7, "gross_charge": 758.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000073", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73100", "type": "HCPCS" } ], "description": "Hc Xr Wrist 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 147.55, "gross_charge": 227.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000073_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73100", "type": "HCPCS" } ], "description": "Hc Xr Wrist 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 295.1, "gross_charge": 454.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000074", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73110", "type": "HCPCS" } ], "description": "Hc Xr Wrist Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 182.0, "gross_charge": 280.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000074_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73110", "type": "HCPCS" } ], "description": "Hc Xr Wrist Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 364.0, "gross_charge": 560.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000075", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73115", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Wrist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 533.65, "gross_charge": 821.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000075_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73115", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Wrist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1067.3, "gross_charge": 1642.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000076", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73120", "type": "HCPCS" } ], "description": "Hc Xr Hand 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 159.9, "gross_charge": 246.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000076_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73120", "type": "HCPCS" } ], "description": "Hc Xr Hand 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 319.8, "gross_charge": 492.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000077", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73130", "type": "HCPCS" } ], "description": "Hc Xr Hand Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 208.0, "gross_charge": 320.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000077_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73130", "type": "HCPCS" } ], "description": "Hc Xr Hand Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 416.0, "gross_charge": 640.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000078", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73140", "type": "HCPCS" } ], "description": "Hc Xr Fingers 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 165.1, "gross_charge": 254.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000078_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73140", "type": "HCPCS" } ], "description": "Hc Xr Fingers 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 330.2, "gross_charge": 508.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000082", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73525", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Hip", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 561.6, "gross_charge": 864.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000082_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73525", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Hip", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1123.2, "gross_charge": 1728.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000086", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73560", "type": "HCPCS" } ], "description": "Hc Xr Knee 1 Or 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 204.1, "gross_charge": 314.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000086_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73560", "type": "HCPCS" } ], "description": "Hc Xr Knee 1 Or 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 408.2, "gross_charge": 628.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000087", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73562", "type": "HCPCS" } ], "description": "Hc Xr Knee 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.05, "gross_charge": 377.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000087_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73562", "type": "HCPCS" } ], "description": "Hc Xr Knee 3 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 490.1, "gross_charge": 754.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000088", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73564", "type": "HCPCS" } ], "description": "Hc Xr Knee Complete 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 263.9, "gross_charge": 406.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000088_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73564", "type": "HCPCS" } ], "description": "Hc Xr Knee Complete 4 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 527.8, "gross_charge": 812.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000089", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73565", "type": "HCPCS" } ], "description": "Hc Xr Knee Ap Standing Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 209.3, "gross_charge": 322.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000090", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73580", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Knee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 509.6, "gross_charge": 784.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000090_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73580", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Knee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1019.2, "gross_charge": 1568.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000091", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73590", "type": "HCPCS" } ], "description": "Hc Xr Tibia Fibula 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 199.55, "gross_charge": 307.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000091_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73590", "type": "HCPCS" } ], "description": "Hc Xr Tibia Fibula 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 399.1, "gross_charge": 614.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000092", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73592", "type": "HCPCS" } ], "description": "Hc Xr Lower Extremity Infant 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 189.15, "gross_charge": 291.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000092_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73592", "type": "HCPCS" } ], "description": "Hc Xr Lower Extremity Infant 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 378.3, "gross_charge": 582.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000093", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73600", "type": "HCPCS" } ], "description": "Hc Xr Ankle 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 218.4, "gross_charge": 336.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000093_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73600", "type": "HCPCS" } ], "description": "Hc Xr Ankle 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 436.8, "gross_charge": 672.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000094", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73610", "type": "HCPCS" } ], "description": "Hc Xr Ankle Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 241.15, "gross_charge": 371.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000094_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73610", "type": "HCPCS" } ], "description": "Hc Xr Ankle Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 482.3, "gross_charge": 742.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000095", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73615", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Ankle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 509.6, "gross_charge": 784.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000095_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73615", "type": "HCPCS" } ], "description": "Hc Xr Arthrogram Ankle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1019.2, "gross_charge": 1568.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000096", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73620", "type": "HCPCS" } ], "description": "Hc Xr Foot 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 184.6, "gross_charge": 284.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000096_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73620", "type": "HCPCS" } ], "description": "Hc Xr Foot 2 Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 369.2, "gross_charge": 568.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000097", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73630", "type": "HCPCS" } ], "description": "Hc Xr Foot Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.05, "gross_charge": 377.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000097_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73630", "type": "HCPCS" } ], "description": "Hc Xr Foot Complete 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 490.1, "gross_charge": 754.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000098", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73650", "type": "HCPCS" } ], "description": "Hc Xr Calcaneus 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 208.0, "gross_charge": 320.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000098_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73650", "type": "HCPCS" } ], "description": "Hc Xr Calcaneus 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 416.0, "gross_charge": 640.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000099", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73660", "type": "HCPCS" } ], "description": "Hc Xr Toes 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 219.05, "gross_charge": 337.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000099_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73660", "type": "HCPCS" } ], "description": "Hc Xr Toes 2 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 438.1, "gross_charge": 674.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000103", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74022", "type": "HCPCS" } ], "description": "Hc Xr Acute Abdominal Series W 1 Vw Chest", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 359.45, "gross_charge": 553.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000104", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74190", "type": "HCPCS" } ], "description": "Hc Xr Peritoneogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 744.25, "gross_charge": 1145.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000105", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74220", "type": "HCPCS" } ], "description": "Hc Xr Esophagus Single Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 353.6, "gross_charge": 544.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000106", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74230", "type": "HCPCS" } ], "description": "Hc Xr Swallowing Function Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 300.95, "gross_charge": 463.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000107", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74235", "type": "HCPCS" } ], "description": "Hc Remove Fb Esophagus W Balloon Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 742.95, "gross_charge": 1143.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000108", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74240", "type": "HCPCS" } ], "description": "Hc Xr Upper Gi Single Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 534.95, "gross_charge": 823.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000111", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74246", "type": "HCPCS" } ], "description": "Hc Xr Upper Gi Double Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 626.6, "gross_charge": 964.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000114", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74250", "type": "HCPCS" } ], "description": "Hc Xr Small Intestine Single Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 494.0, "gross_charge": 760.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000115", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74251", "type": "HCPCS" } ], "description": "Hc Xr Small Intestine Double Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 620.1, "gross_charge": 954.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000116", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74270", "type": "HCPCS" } ], "description": "Hc Xr Colon Single Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 528.45, "gross_charge": 813.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000117", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74280", "type": "HCPCS" } ], "description": "Hc Xr Colon Double Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 665.6, "gross_charge": 1024.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000120", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74300", "type": "HCPCS" } ], "description": "Hc Cholangiogram Intraop", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 390.65, "gross_charge": 601.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000121", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74301", "type": "HCPCS" } ], "description": "Hc Cholangiogram Intraop Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 200.2, "gross_charge": 308.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000125", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74330", "type": "HCPCS" } ], "description": "Hc Xr Ercp Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 713.05, "gross_charge": 1097.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000126", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74340", "type": "HCPCS" } ], "description": "Hc Xr Introduction Long Gi Tube W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 457.6, "gross_charge": 704.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000127", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74355", "type": "HCPCS" } ], "description": "Hc Placement Enteroclysis Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 734.5, "gross_charge": 1130.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000128", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74360", "type": "HCPCS" } ], "description": "Hc Intraluminal Dilation Esoph", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 452.4, "gross_charge": 696.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000129", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74363", "type": "HCPCS" } ], "description": "Hc Dilation Biliary Duct Strictures", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 866.45, "gross_charge": 1333.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000130", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74400", "type": "HCPCS" } ], "description": "Hc Urogram Intravenous (Ivp) W Or Wo Kub Or Tomogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 733.85, "gross_charge": 1129.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000133", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74420", "type": "HCPCS" } ], "description": "Hc Urogram Retrograde W Or Wo Kub", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 831.35, "gross_charge": 1279.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000134", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74425", "type": "HCPCS" } ], "description": "Hc Urogram Antegrade", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 510.25, "gross_charge": 785.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000135", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74430", "type": "HCPCS" } ], "description": "Hc Cystogram 3 + Vw", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 472.55, "gross_charge": 727.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000136", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74445", "type": "HCPCS" } ], "description": "Hc Corpora Cavernosogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1454.05, "gross_charge": 2237.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000137", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74450", "type": "HCPCS" } ], "description": "Hc Urethrocystogram Retrograde", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 614.25, "gross_charge": 945.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000138", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74455", "type": "HCPCS" } ], "description": "Hc Urethrocystogram Voiding", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 661.05, "gross_charge": 1017.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000139", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74470", "type": "HCPCS" } ], "description": "Hc Xr Renal Cyst Study Translumbar", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2323.75, "gross_charge": 3575.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000142", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74485", "type": "HCPCS" } ], "description": "Hc Dilation Ureters Or Urethra", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2193.75, "gross_charge": 3375.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000143", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74740", "type": "HCPCS" } ], "description": "Hc Hysterosalpingogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 384.8, "gross_charge": 592.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000144", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74742", "type": "HCPCS" } ], "description": "Hc Transcervical Cath Fallopian Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1293.5, "gross_charge": 1990.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000145", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74775", "type": "HCPCS" } ], "description": "Hc Perineogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1122.55, "gross_charge": 1727.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000146", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75803", "type": "HCPCS" } ], "description": "Hc Lymphangiogram Extremity Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1963.0, "gross_charge": 3020.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000147", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75805", "type": "HCPCS" } ], "description": "Hc Lymphangiogram Pelvic Abdominal Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2280.85, "gross_charge": 3509.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000148", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75807", "type": "HCPCS" } ], "description": "Hc Lymphangiogram Pelvic Abdominal Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000149", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75809", "type": "HCPCS" } ], "description": "Hc Shuntogram Nonvascular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 389.35, "gross_charge": 599.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000150", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75810", "type": "HCPCS" } ], "description": "Hc Splenoportogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4351.1, "gross_charge": 6694.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000151", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75820", "type": "HCPCS" } ], "description": "Hc Venogram Extremity Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 758.55, "gross_charge": 1167.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000152", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75822", "type": "HCPCS" } ], "description": "Hc Venogram Extremity Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1331.2, "gross_charge": 2048.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000153", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75825", "type": "HCPCS" } ], "description": "Hc Venocavagram Inferior", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000154", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75827", "type": "HCPCS" } ], "description": "Hc Venocavagram Superior", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1448.85, "gross_charge": 2229.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000155", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75831", "type": "HCPCS" } ], "description": "Hc Venogram Renal Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000156", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75833", "type": "HCPCS" } ], "description": "Hc Venogram Renal Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3687.45, "gross_charge": 5673.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000157", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75840", "type": "HCPCS" } ], "description": "Hc Venogram Adrenal Unilatateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000158", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75842", "type": "HCPCS" } ], "description": "Hc Venogram Adrenal Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5526.3, "gross_charge": 8502.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000159", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75860", "type": "HCPCS" } ], "description": "Hc Venogram Sinus Jugular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000160", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75870", "type": "HCPCS" } ], "description": "Hc Venogram Superior Sagittal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2208.05, "gross_charge": 3397.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000161", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75872", "type": "HCPCS" } ], "description": "Hc Venogram Epidural", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3087.5, "gross_charge": 4750.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000162", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75885", "type": "HCPCS" } ], "description": "Hc Portogram W Hemodynamics", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000163", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75887", "type": "HCPCS" } ], "description": "Hc Portogram Wo Hemodynamics", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000164", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75889", "type": "HCPCS" } ], "description": "Hc Venogram Hepatic W Hemodynamics", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000165", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75891", "type": "HCPCS" } ], "description": "Hc Venogram Hepatic Wo Hemodynamics", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000166", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75893", "type": "HCPCS" } ], "description": "Hc Venous Sampling Through Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5526.3, "gross_charge": 8502.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000167", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75894", "type": "HCPCS" } ], "description": "Hc Transcath Therapy Embolization", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1898.0, "gross_charge": 2920.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000169", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75898", "type": "HCPCS" } ], "description": "Hc Transcath Angio Not Thromblysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2280.85, "gross_charge": 3509.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000170", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75901", "type": "HCPCS" } ], "description": "Hc Removal Of Fibrin Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 447.85, "gross_charge": 689.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000171", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75902", "type": "HCPCS" } ], "description": "Hc Mech Remvl Intraluminal Obstructive Material", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 343.85, "gross_charge": 529.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000177", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75956", "type": "HCPCS" } ], "description": "Hc Endovasc Rep Descending Thoracic Aorta Subclavian", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1097.85, "gross_charge": 1689.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000178", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75957", "type": "HCPCS" } ], "description": "Hc Endovasc Rep Descending Thoracic Aorta Celiac", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 941.2, "gross_charge": 1448.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000179", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75958", "type": "HCPCS" } ], "description": "Hc Proximal Exten Prosth Descending Thoracic Aorta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1259.7, "gross_charge": 1938.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000180", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75959", "type": "HCPCS" } ], "description": "Hc Distal Exten Prosth Descending Thoracic Aorta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1097.85, "gross_charge": 1689.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000186", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75970", "type": "HCPCS" } ], "description": "Hc Transcatheter Biopsy R S&I", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1873.3, "gross_charge": 2882.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000190", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75984", "type": "HCPCS" } ], "description": "Hc Drainage Catheter Exchange W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 448.5, "gross_charge": 690.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000191", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75989", "type": "HCPCS" } ], "description": "Hc Rad Guidance For Drainage W Cath Placement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 970.45, "gross_charge": 1493.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000192", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "76000", "type": "HCPCS" } ], "description": "Hc Fluoro Up To 1 Hour Separate Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 357.5, "gross_charge": 550.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000194", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "76010", "type": "HCPCS" } ], "description": "Hc Xr Nose To Rectum For Foreign Body Child", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 618.8, "gross_charge": 952.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000195", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "76080", "type": "HCPCS" } ], "description": "Hc Xr Abscess Fistula Sinus Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 596.7, "gross_charge": 918.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000196", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "76098", "type": "HCPCS" } ], "description": "Hc Rad Exam Surgical Specimen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 628.55, "gross_charge": 967.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000197", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "76100", "type": "HCPCS" } ], "description": "Hc Xr Tomogram Single Plane", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 492.05, "gross_charge": 757.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000199", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "76496", "type": "HCPCS" } ], "description": "Hc Unlisted Fluoro Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 267.8, "gross_charge": 412.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000201", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77001", "type": "HCPCS" } ], "description": "Hc Fluoro Central Venous Access Placement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 436.8, "gross_charge": 672.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000202", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77002", "type": "HCPCS" } ], "description": "Hc Fluoro Guided Needle Placement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 290.55, "gross_charge": 447.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000203", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77003", "type": "HCPCS" } ], "description": "Hc Fluoro Guided Spinal Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.7, "gross_charge": 378.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000206", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77053", "type": "HCPCS" } ], "description": "Hc Mammary Ductogram Or Galactogram Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 336.05, "gross_charge": 517.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000207", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77054", "type": "HCPCS" } ], "description": "Hc Mammary Ductogram Or Galactogram Mult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 336.05, "gross_charge": 517.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000209", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77072", "type": "HCPCS" } ], "description": "Hc Bone Age Studies", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 205.4, "gross_charge": 316.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000210", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77073", "type": "HCPCS" } ], "description": "Hc Bone Length Studies", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 223.6, "gross_charge": 344.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000211", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77074", "type": "HCPCS" } ], "description": "Hc Xr Bone Survey Limited", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 282.75, "gross_charge": 435.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000212", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77075", "type": "HCPCS" } ], "description": "Hc Xr Bone Survey Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 515.45, "gross_charge": 793.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000213", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77076", "type": "HCPCS" } ], "description": "Hc Xr Bone Survey Infant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 282.75, "gross_charge": 435.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000214", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77077", "type": "HCPCS" } ], "description": "Hc Joint Survey Single View", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 215.8, "gross_charge": 332.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000215", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77080", "type": "HCPCS" } ], "description": "Hc Bone Density Dexa Axial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 291.2, "gross_charge": 448.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000216", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77081", "type": "HCPCS" } ], "description": "Hc Bone Density Dexa Appendicular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 203.45, "gross_charge": 313.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000220", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74328", "type": "HCPCS" } ], "description": "Hc Xr Ercp Biliary Ductal System Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 445.25, "gross_charge": 685.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000221", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74329", "type": "HCPCS" } ], "description": "Hc Xr Ercp Pancreatic Ductal System Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 445.25, "gross_charge": 685.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000223", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "75801", "type": "HCPCS" } ], "description": "Hc Lymphangiogram Extremity Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 815.1, "gross_charge": 1254.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000224", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77085", "type": "HCPCS" } ], "description": "Hc Xr Bone Density Dexa Axial And Verteb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 452.4, "gross_charge": 696.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000225", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77086", "type": "HCPCS" } ], "description": "Hc Xr Dexa Vertebral Fracture Assess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 116.35, "gross_charge": 179.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000226", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72081", "type": "HCPCS" } ], "description": "Hc Xr Spine Entire Thoracic And Lumbar 1 View", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.0, "gross_charge": 200.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000227", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72082", "type": "HCPCS" } ], "description": "Hc Xr Spine Entire Thoracic And Lumbar 2-3 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 237.25, "gross_charge": 365.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000228", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72083", "type": "HCPCS" } ], "description": "Hc Xr Spine Entire Thoracic And Lumbar 4-5 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 283.4, "gross_charge": 436.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000229", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "72084", "type": "HCPCS" } ], "description": "Hc Xr Spine Entire Thoracic And Lumbar 6+ Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 333.45, "gross_charge": 513.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000230", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73501", "type": "HCPCS" } ], "description": "Hc Xr Hip Unilateral 1 View", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 207.35, "gross_charge": 319.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000231", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73502", "type": "HCPCS" } ], "description": "Hc Xr Hip Unilateral W Pelvis 2-3 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 235.3, "gross_charge": 362.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000232", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73503", "type": "HCPCS" } ], "description": "Hc Xr Hip Unilateral W Pelvis 4+ Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 263.9, "gross_charge": 406.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000233", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73521", "type": "HCPCS" } ], "description": "Hc Xr Hips Bilateral 2 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 215.15, "gross_charge": 331.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000234", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73522", "type": "HCPCS" } ], "description": "Hc Xr Hips Bilateral W Pelvis 3-4 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 315.25, "gross_charge": 485.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000235", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73523", "type": "HCPCS" } ], "description": "Hc Xr Hips Bilateral W Pelvis 5+ Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 354.9, "gross_charge": 546.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000236", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73551", "type": "HCPCS" } ], "description": "Hc Xr Femur 1 View", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000236_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73551", "type": "HCPCS" } ], "description": "Hc Xr Femur 1 View", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 249.6, "gross_charge": 384.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000237", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73552", "type": "HCPCS" } ], "description": "Hc Xr Femur 2+ Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 152.75, "gross_charge": 235.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000237_50", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "73552", "type": "HCPCS" } ], "description": "Hc Xr Femur 2+ Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 305.5, "gross_charge": 470.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "32000239", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74018", "type": "HCPCS" } ], "description": "Hc Xr Abdomen 1 View", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 163.15, "gross_charge": 251.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000240", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74019", "type": "HCPCS" } ], "description": "Hc Xr Abdomen 2 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 252.2, "gross_charge": 388.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000241", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74021", "type": "HCPCS" } ], "description": "Hc Xr Abdomen 3+ Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 263.9, "gross_charge": 406.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000242", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "77071", "type": "HCPCS" } ], "description": "Hc Xr Manual Appl Of Stress For Joint Xray", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 156.65, "gross_charge": 241.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000243", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74221", "type": "HCPCS" } ], "description": "Hc Xr Esophagus Double Contrast Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 497.25, "gross_charge": 765.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000244", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "74248", "type": "HCPCS" } ], "description": "Hc Xr Small Intestine Follow Through Study Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 378.3, "gross_charge": 582.0, "setting": "both" } ] }, { "code_information": [ { "code": "32000245", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "76145", "type": "HCPCS" } ], "description": "Hc Medical Physics Dose Eval For Radiation Exposure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1944.15, "gross_charge": 2991.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300001", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75605", "type": "HCPCS" } ], "description": "Hc Aortogram Thoracic Serialogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5639.4, "gross_charge": 8676.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300002", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75625", "type": "HCPCS" } ], "description": "Hc Aortogram Abdominal Serialogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300003", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75630", "type": "HCPCS" } ], "description": "Hc Aortogram Abd W Bilat Ileofemoral Low Ext", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3522.35, "gross_charge": 5419.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300005", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75705", "type": "HCPCS" } ], "description": "Hc Angiogram Spinal Selective", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5526.3, "gross_charge": 8502.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300006", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75710", "type": "HCPCS" } ], "description": "Hc Angiogram Extremity Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300007", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75716", "type": "HCPCS" } ], "description": "Hc Angiogram Extremity Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3409.25, "gross_charge": 5245.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300008", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75726", "type": "HCPCS" } ], "description": "Hc Angiogram Visceral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5526.3, "gross_charge": 8502.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300009", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75731", "type": "HCPCS" } ], "description": "Hc Angiogram Adrenal Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2198.95, "gross_charge": 3383.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300010", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75733", "type": "HCPCS" } ], "description": "Hc Angiogram Adrenal Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300011", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75736", "type": "HCPCS" } ], "description": "Hc Angiogram Pelvic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5526.3, "gross_charge": 8502.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300012", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75741", "type": "HCPCS" } ], "description": "Hc Angiogram Pulmonary Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3332.55, "gross_charge": 5127.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300013", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75743", "type": "HCPCS" } ], "description": "Hc Angiogram Pulmonary Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3378.05, "gross_charge": 5197.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300014", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75746", "type": "HCPCS" } ], "description": "Hc Angiogram Pulmonary Non-Select", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3115.45, "gross_charge": 4793.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300015", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75756", "type": "HCPCS" } ], "description": "Hc Internal Mammary Arteriogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1785.55, "gross_charge": 2747.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300016", "type": "CDM" }, { "code": "323", "type": "RC" }, { "code": "75774", "type": "HCPCS" } ], "description": "Hc Angiogram Each Addl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1345.5, "gross_charge": 2070.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300019", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "G0278", "type": "HCPCS" } ], "description": "Hc Angio Iliac Artery W Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2951.65, "gross_charge": 4541.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300020", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0338T", "type": "HCPCS" } ], "description": "Hc Renal Transcath Sympath Denerv Uni", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10592.4, "gross_charge": 16296.0, "setting": "both" } ] }, { "code_information": [ { "code": "32300021", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0339T", "type": "HCPCS" } ], "description": "Hc Renal Transcath Sympath Denerv Bil", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14123.2, "gross_charge": 21728.0, "setting": "both" } ] }, { "code_information": [ { "code": "32400009", "type": "CDM" }, { "code": "324", "type": "RC" }, { "code": "71047", "type": "HCPCS" } ], "description": "Hc Xr Chest 3 Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 250.9, "gross_charge": 386.0, "setting": "both" } ] }, { "code_information": [ { "code": "32400010", "type": "CDM" }, { "code": "324", "type": "RC" }, { "code": "71048", "type": "HCPCS" } ], "description": "Hc Xr Chest 4+ Views", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 273.65, "gross_charge": 421.0, "setting": "both" } ] }, { 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"billing_class": "facility", "discounted_cash": 257.4, "gross_charge": 396.0, "setting": "both" } ] }, { "code_information": [ { "code": "33100002", "type": "CDM" }, { "code": "331", "type": "RC" }, { "code": "96402", "type": "HCPCS" } ], "description": "Hc Chemo Sq Im Horm Antineoplast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 257.4, "gross_charge": 396.0, "setting": "both" } ] }, { "code_information": [ { "code": "33100003", "type": "CDM" }, { "code": "331", "type": "RC" }, { "code": "96405", "type": "HCPCS" } ], "description": "Hc Chemo Intralesional Up To 7 Lesions", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 196.3, "gross_charge": 302.0, "setting": "both" } ] }, { "code_information": [ { "code": "33100004", "type": "CDM" }, { "code": "331", "type": "RC" }, { "code": "96409", "type": "HCPCS" } ], 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Type: Standard", "billing_class": "facility", "discounted_cash": 394.55, "gross_charge": 607.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300001", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77280", "type": "HCPCS" } ], "description": "Hc Therapeutic Radiation Simulation Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1049.1, "gross_charge": 1614.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300002", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77285", "type": "HCPCS" } ], "description": "Hc Therapeutic Radiation Simulation Intermediate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1912.3, "gross_charge": 2942.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300003", "type": "CDM" }, { "code": "333", "type": "RC" }, { 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"gross_charge": 2762.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300007", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77301", "type": "HCPCS" } ], "description": "Hc Imrt Planning", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12989.6, "gross_charge": 19984.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300011", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77321", "type": "HCPCS" } ], "description": "Hc Special Teletherapy Port Plan", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5023.2, "gross_charge": 7728.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300015", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77331", "type": "HCPCS" } ], "description": "Hc Dosimetry Special", "standard_charges": [ { 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"type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77334", "type": "HCPCS" } ], "description": "Hc Treatment Devices Desgn And Cnstrct Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1143.35, "gross_charge": 1759.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300019", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77336", "type": "HCPCS" } ], "description": "Hc Medical Physics Consult Continuing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1574.95, "gross_charge": 2423.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300020", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77338", "type": "HCPCS" } ], "description": "Hc Mlc Imrt Device Desgn And Cnstrct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1107.6, "gross_charge": 1704.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300021", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77370", "type": "HCPCS" } ], "description": "Hc Medical Physics Special Consultation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2093.65, "gross_charge": 3221.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300031", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77417", "type": "HCPCS" } ], "description": "Hc Therapeutic Radiology Port Film(S)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 544.7, "gross_charge": 838.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300034", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77470", "type": "HCPCS" } ], "description": "Hc Special Treatment Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2743.0, "gross_charge": 4220.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300035", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77605", "type": "HCPCS" } ], "description": "Hc Hyperthermia Ext Generated Deep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3087.5, "gross_charge": 4750.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300041", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77778", "type": "HCPCS" } ], "description": "Hc Interstitial Radiation Source Application Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3207.75, "gross_charge": 4935.0, "setting": 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"additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3263.65, "gross_charge": 5021.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300053", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77293", "type": "HCPCS" } ], "description": "Hc Resp Motion Mgmt Simulation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2221.7, "gross_charge": 3418.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300054", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77306", "type": "HCPCS" } ], "description": "Hc Tele Isodose Plan Simple Incl Dosim", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6947.2, "gross_charge": 10688.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300055", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77307", "type": "HCPCS" } ], "description": "Hc Tele Isodose Plan Complex Incl Dosim", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8553.35, "gross_charge": 13159.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300056", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77316", "type": "HCPCS" } ], "description": "Hc Isodose Brachy Simple Incl Dosim", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3168.75, "gross_charge": 4875.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300057", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77317", "type": "HCPCS" } ], "description": "Hc Isodose Brachy Interm Incl Dosim", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5525.0, "gross_charge": 8500.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300058", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77318", "type": "HCPCS" } ], "description": "Hc Isodose Brachy Complex Incl Dosim", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5525.0, "gross_charge": 8500.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300059", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77385", "type": "HCPCS" } ], "description": "Hc Imrt Simple Incl Image Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2627.3, "gross_charge": 4042.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300060", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77386", "type": "HCPCS" } ], "description": "Hc Imrt Complex 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"code": "33300063", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77407", "type": "HCPCS" } ], "description": "Hc Radiation Trtmnt Delivery Intermed", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1210.3, "gross_charge": 1862.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300064", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77412", "type": "HCPCS" } ], "description": "Hc Radiation Trtmnt Delivery; Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1326.0, "gross_charge": 2040.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300065", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77770", "type": "HCPCS" } ], "description": "Hc Hdr Interstitial Or Intracavitar 1 Channel, Incl Dosimetry", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6654.7, "gross_charge": 10238.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300066", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77771", "type": "HCPCS" } ], "description": "Hc Hdr Interstitial Or Intracavitary, 2-12 Channels, Incl Dosimetry", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6654.7, "gross_charge": 10238.0, "setting": "both" } ] }, { "code_information": [ { "code": "33300067", "type": "CDM" }, { "code": "333", "type": "RC" }, { "code": "77772", "type": "HCPCS" } ], "description": "Hc Hdr Interstitial Or Intracavitary, >12 Channels, Incl Dosimetry", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6654.7, "gross_charge": 10238.0, "setting": "both" } ] }, { 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"gross_charge": 2329.0, "setting": "both" } ] }, { "code_information": [ { "code": "34200004", "type": "CDM" }, { "code": "342", "type": "RC" }, { "code": "79403", "type": "HCPCS" } ], "description": "Hc Radiotherapy Radiolabeled Monoclonal Ab Iv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2605.2, "gross_charge": 4008.0, "setting": "both" } ] }, { "code_information": [ { "code": "34200005", "type": "CDM" }, { "code": "342", "type": "RC" }, { "code": "79445", "type": "HCPCS" } ], "description": "Hc Radiopharm Therapy Intra Arterial Administration", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1225.9, "gross_charge": 1886.0, "setting": "both" } ] }, { "code_information": [ { "code": "34300034_343", "type": "CDM" }, { "code": "343", "type": "RC" } ], "description": "Noncdm Charge Record Radiopharmaceuticals", 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"type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1002", "type": "HCPCS" } ], "description": "Hc Cdsm Medcurrent G1002", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000012", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1003", "type": "HCPCS" } ], "description": "Hc Cdsm Medicalis G1003", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000013", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1004", "type": "HCPCS" } ], "description": "Hc Cdsm Ndsc G1004", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000016", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1007", "type": "HCPCS" } ], "description": "Hc Cdsm Aim G1007", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000017", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1008", "type": "HCPCS" } ], "description": "Hc Cdsm Cranberry Peak G1008", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000018", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1009", "type": "HCPCS" } ], "description": "Hc Cdsm Sage G1009", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000019", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1010", "type": "HCPCS" } ], "description": "Hc Cdsm Stanson G1010", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000020", "type": "CDM" }, { "code": "320", "type": "RC" }, { "code": "G1011", "type": "HCPCS" } ], "description": "Hc Cdsm Nos G1011", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "35000024", "type": "CDM" }, { "code": "350", "type": "RC" }, { "code": "0944T", "type": "HCPCS" } ], "description": "Hc 3D Contour Simulation Liver For Lesion Microwave Ablation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 542.75, "gross_charge": 835.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100001", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70450", "type": "HCPCS" } ], "description": "Hc Ct Brain Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 835.25, "gross_charge": 1285.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100002", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70460", "type": "HCPCS" } ], "description": "Hc Ct Brain W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 950.95, "gross_charge": 1463.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100003", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70470", "type": "HCPCS" } ], "description": "Hc Ct Brain W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1077.7, "gross_charge": 1658.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100004", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70480", "type": "HCPCS" } ], "description": "Hc Ct Orbit Sella Post Fossa Ear Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 861.9, "gross_charge": 1326.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100005", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70481", "type": "HCPCS" } ], "description": "Hc Ct Orbit Sella Post Fossa Ear W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1054.95, "gross_charge": 1623.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100006", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70482", "type": "HCPCS" } ], "description": "Hc Ct Orbit Sella Post Fossa Ear W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1248.0, "gross_charge": 1920.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100007", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70486", "type": "HCPCS" } ], "description": "Hc Ct Maxillofacial Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 875.55, "gross_charge": 1347.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100008", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70487", "type": "HCPCS" } ], "description": "Hc Ct Maxillofacial W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1150.5, "gross_charge": 1770.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100009", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70488", "type": "HCPCS" } ], "description": "Hc Ct Maxillofacial W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1259.7, "gross_charge": 1938.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100010", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70490", "type": "HCPCS" } ], "description": "Hc Ct Soft Tissue Neck Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 995.15, "gross_charge": 1531.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100011", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70491", "type": "HCPCS" } ], "description": "Hc Ct Soft Tissue Neck W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1181.7, "gross_charge": 1818.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100012", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70492", "type": "HCPCS" } ], "description": "Hc Ct Soft Tissue Neck W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1274.0, "gross_charge": 1960.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100013", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70496", "type": "HCPCS" } ], "description": "Hc Cta Head W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1301.95, "gross_charge": 2003.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100014", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "70498", "type": "HCPCS" } ], "description": "Hc Cta Neck W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1300.65, "gross_charge": 2001.0, "setting": "both" } ] }, { "code_information": [ { "code": "35100015", "type": "CDM" }, { "code": "351", "type": "RC" }, { "code": "0042T", "type": "HCPCS" } ], "description": "Hc Ct Cerebral Perf Analysis With Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1348.75, "gross_charge": 2075.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200001", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "71250", "type": "HCPCS" } ], "description": "Hc Ct Chest Diagnostic Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 996.45, "gross_charge": 1533.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200002", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "71260", "type": "HCPCS" } ], "description": "Hc Ct Chest Diagnostic W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1368.9, "gross_charge": 2106.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200003", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "71270", "type": "HCPCS" } ], "description": "Hc Ct Chest Diagnostic W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1633.45, "gross_charge": 2513.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200004", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "71275", "type": "HCPCS" } ], "description": "Hc Cta Chest W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1416.35, "gross_charge": 2179.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200005", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72125", "type": "HCPCS" } ], "description": "Hc Ct Cervical Spine Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1073.15, "gross_charge": 1651.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200006", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72126", "type": "HCPCS" } ], "description": "Hc Ct Cervical Spine W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1180.4, "gross_charge": 1816.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200007", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72127", "type": "HCPCS" } ], "description": "Hc Ct Cervical Spine W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1241.5, "gross_charge": 1910.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200008", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72128", "type": "HCPCS" } ], "description": "Hc Ct Thoracic Spine Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 835.25, "gross_charge": 1285.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200009", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72129", "type": "HCPCS" } ], "description": "Hc Ct Thoracic Spine W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1005.55, "gross_charge": 1547.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200010", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72130", "type": "HCPCS" } ], "description": "Hc Ct Thoracic Spine W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1107.6, "gross_charge": 1704.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200011", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72131", "type": "HCPCS" } ], "description": "Hc Ct Lumbar Spine Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 867.75, "gross_charge": 1335.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200012", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72132", "type": "HCPCS" } ], "description": "Hc Ct Lumbar Spine W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 950.95, "gross_charge": 1463.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200013", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72133", "type": "HCPCS" } ], "description": "Hc Ct Lumbar Spine W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1128.4, "gross_charge": 1736.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200014", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72191", "type": "HCPCS" } ], "description": "Hc Cta Pelvis W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1242.8, "gross_charge": 1912.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200015", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72192", "type": "HCPCS" } ], "description": "Hc Ct Pelvis Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1019.85, "gross_charge": 1569.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200016", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72193", "type": "HCPCS" } ], "description": "Hc Ct Pelvis W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1101.1, "gross_charge": 1694.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200017", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "72194", "type": "HCPCS" } ], "description": "Hc Ct Pelvis W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1182.35, "gross_charge": 1819.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200019", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73200", "type": "HCPCS" } ], "description": "Hc Ct Upper Extremity Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 846.95, "gross_charge": 1303.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200019_50", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73200", "type": "HCPCS" } ], "description": "Hc Ct Upper Extremity Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1693.9, "gross_charge": 2606.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "35200020", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73201", "type": "HCPCS" } ], "description": "Hc Ct Upper Extremity W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1019.85, "gross_charge": 1569.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200020_50", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73201", "type": "HCPCS" } ], "description": "Hc Ct Upper Extremity W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2039.7, "gross_charge": 3138.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "35200021", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73202", "type": "HCPCS" } ], "description": "Hc Ct Upper Extremity W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1106.95, "gross_charge": 1703.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200021_50", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73202", "type": "HCPCS" } ], "description": "Hc Ct Upper Extremity W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2213.9, "gross_charge": 3406.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "35200022", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73206", "type": "HCPCS" } ], "description": "Hc Cta Upper Extremity W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1361.1, "gross_charge": 2094.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200023", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73700", "type": "HCPCS" } ], "description": "Hc Ct Lower Extrem Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 872.3, "gross_charge": 1342.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200023_50", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73700", "type": "HCPCS" } ], "description": "Hc Ct Lower Extrem Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1744.6, "gross_charge": 2684.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "35200024", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73701", "type": "HCPCS" } ], "description": "Hc Ct Lower Extrem W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1014.0, "gross_charge": 1560.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200024_50", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73701", "type": "HCPCS" } ], "description": "Hc Ct Lower Extrem W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2028.0, "gross_charge": 3120.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "35200025", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73702", "type": "HCPCS" } ], "description": "Hc Ct Lower Extrem W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1231.75, "gross_charge": 1895.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200025_50", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73702", "type": "HCPCS" } ], "description": "Hc Ct Lower Extrem W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2463.5, "gross_charge": 3790.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "35200026", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73706", "type": "HCPCS" } ], "description": "Hc Cta Lower Extrem W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1343.55, "gross_charge": 2067.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200026_50", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "73706", "type": "HCPCS" } ], "description": "Hc Cta Lower Extrem W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2687.1, "gross_charge": 4134.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "35200027", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74150", "type": "HCPCS" } ], "description": "Hc Ct Abdomen Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1068.6, "gross_charge": 1644.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200028", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74160", "type": "HCPCS" } ], "description": "Hc Ct Abdomen W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1167.4, "gross_charge": 1796.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200029", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74170", "type": "HCPCS" } ], "description": "Hc Ct Abdomen W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1266.2, "gross_charge": 1948.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200030", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74174", "type": "HCPCS" } ], "description": "Hc Cta Abdomen Pelvis W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2152.8, "gross_charge": 3312.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200031", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74175", "type": "HCPCS" } ], "description": "Hc Cta Abdomen W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1329.9, "gross_charge": 2046.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200032", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74176", "type": "HCPCS" } ], "description": "Hc Ct Abdomen Pelvis Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1571.05, "gross_charge": 2417.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200033", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74177", "type": "HCPCS" } ], "description": "Hc Ct Abdomen Pelvis W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1931.8, "gross_charge": 2972.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200034", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74178", "type": "HCPCS" } ], "description": "Hc Ct Abdomen Pelvis W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2051.4, "gross_charge": 3156.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200035", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74261", "type": "HCPCS" } ], "description": "Hc Ct Colonogram Diagnostic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 816.4, "gross_charge": 1256.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200036", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "74263", "type": "HCPCS" } ], "description": "Hc Ct Colonogram Screening", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 816.4, "gross_charge": 1256.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200037", "type": "CDM" }, { "code": "352", "type": "RC" } ], "description": "Hc Ct Coronary Calcium Scan Screening", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 61.75, "gross_charge": 95.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200038", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "75572", "type": "HCPCS" } ], "description": "Hc Ct Heart Contrast Eval Card Function", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 995.8, "gross_charge": 1532.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200039", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "75573", "type": "HCPCS" } ], "description": "Hc Ct Heart Contrast Eval Card Function Congenital", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1115.4, "gross_charge": 1716.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200040", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "75574", "type": "HCPCS" } ], "description": "Hc Cta Heart W Dye Cor Ateries And Bypass Grafts", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1220.7, "gross_charge": 1878.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200041", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "75635", "type": "HCPCS" } ], "description": "Hc Cta Abd Aorta Bilateral Lower Ext Runoff", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 913.25, "gross_charge": 1405.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200043", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "71271", "type": "HCPCS" } ], "description": "Hc Ct Chest Low Dose Lung Cancer Screening Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 345.8, "gross_charge": 532.0, "setting": "both" } ] }, { "code_information": [ { "code": "35200044", "type": "CDM" }, { "code": "352", "type": "RC" }, { "code": "75571", "type": "HCPCS" } ], "description": "Hc Ct Coronary Calcium Scan Diagnostic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 380.25, "gross_charge": 585.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000001", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "59855", "type": "HCPCS" } ], "description": "Hc Induced Del After Partial Miscarriage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4954.3, "gross_charge": 7622.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000004", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33967", "type": "HCPCS" } ], "description": "Hc Insertion Iabp Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2407.6, "gross_charge": 3704.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000005", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33975", "type": "HCPCS" } ], "description": "Hc Vad Insert Extracorp Single Ventricle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2808.65, "gross_charge": 4321.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000006", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33976", "type": "HCPCS" } ], "description": "Hc Vad Insert Extracorp Biventricular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6657.3, "gross_charge": 10242.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000007", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33977", "type": "HCPCS" } ], "description": "Hc Vad Remove Extracorp Single Ventricle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3494.4, "gross_charge": 5376.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000008", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33978", "type": "HCPCS" } ], "description": "Hc Vad Remove Extracorp Biventricular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3097.25, "gross_charge": 4765.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000009", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "38215", "type": "HCPCS" } ], "description": "Hc Stem Cell / Platelet Concentration", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1727.7, "gross_charge": 2658.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000010", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Anesthesia 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1290.25, "gross_charge": 1985.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000011", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Anesthesia Ea Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 428.35, "gross_charge": 659.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000012", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Assemble Operate Heartlung Machine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15193.75, "gross_charge": 23375.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000013", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Closed Manipulation In Pacu", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 533.0, "gross_charge": 820.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000014", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Closed Reduction In Pacu", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1032.2, "gross_charge": 1588.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000015", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Cont Infusion Nerve Block", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 351.0, "gross_charge": 540.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000016", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc D And C Diagnostic Or Therapeutic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1814.15, "gross_charge": 2791.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000018", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Hemoconcentration", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 595.4, "gross_charge": 916.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000019", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Injection Nerve Block", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1002.3, "gross_charge": 1542.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000020", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Ligation Fallopian Tubes W Bps", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3499.6, "gross_charge": 5384.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000021", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Minor Surgery Or Procedure Per Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2685.15, "gross_charge": 4131.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000022", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Monitor Iabp Per Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1648.4, "gross_charge": 2536.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000023", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Cosmetic 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 533.0, "gross_charge": 820.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000024", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Cosmetic Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 52.0, "gross_charge": 80.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000025", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 1 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2747.55, "gross_charge": 4227.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000026", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 1 1St Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 735.15, "gross_charge": 1131.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000027", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 2 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4850.3, "gross_charge": 7462.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000028", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 2 Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1535.3, "gross_charge": 2362.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000029", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 3 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6899.1, "gross_charge": 10614.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000030", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 3 Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2418.65, "gross_charge": 3721.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000031", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 4 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7996.95, "gross_charge": 12303.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000032", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 4 Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3243.5, "gross_charge": 4990.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000033", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 5 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9074.0, "gross_charge": 13960.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000034", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 5 Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3939.65, "gross_charge": 6061.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000035", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 6 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10351.25, "gross_charge": 15925.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000036", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 6 Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4652.7, "gross_charge": 7158.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000041", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Pacemaker Analysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1106.95, "gross_charge": 1703.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000044", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Procedure Other", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 734.5, "gross_charge": 1130.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000047", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Thermodilution Cardiac Output", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 436.8, "gross_charge": 672.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000048", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Total Hysterectomy Abdominal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4219.8, "gross_charge": 6492.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000049", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "0232T", "type": "HCPCS" } ], "description": "Hc Inj Platelet Rich Plasma", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7781.8, "gross_charge": 11972.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000051", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Bedside Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2744.95, "gross_charge": 4223.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000053", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33990", "type": "HCPCS" } ], "description": "Hc Insert Left Vad Arterial Access Percutaneous W/ Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2739.75, "gross_charge": 4215.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000054", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33991", "type": "HCPCS" } ], "description": "Hc Insert Left Vad Arterial & Venous Access Percutaneous W/ Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2739.75, "gross_charge": 4215.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000055", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33992", "type": "HCPCS" } ], "description": "Hc Remove Left Vad Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1866.15, "gross_charge": 2871.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000056", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33993", "type": "HCPCS" } ], "description": "Hc Reposition Right Or Left Vad Percutaneous W/ Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1630.2, "gross_charge": 2508.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000058", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33946", "type": "HCPCS" } ], "description": "Hc Ecmo Initial Day Veno-Veno", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26989.3, "gross_charge": 41522.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000059", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33947", "type": "HCPCS" } ], "description": "Hc Ecmo Initial Day Veno-Arterial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26989.3, "gross_charge": 41522.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000060", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33948", "type": "HCPCS" } ], "description": "Hc Ecmo Addl Day Veno-Veno", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26989.3, "gross_charge": 41522.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000061", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33949", "type": "HCPCS" } ], "description": "Hc Ecmo Addl Day Veno-Arterial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26989.3, "gross_charge": 41522.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000062", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33979", "type": "HCPCS" } ], "description": "Hc Vad Insert Intracorp Single Ventricle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4187.3, "gross_charge": 6442.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000063", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33980", "type": "HCPCS" } ], "description": "Hc Vad Removal Intracorp Single Ventricle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5534.75, "gross_charge": 8515.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000064", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33981", "type": "HCPCS" } ], "description": "Hc Vad Pump Replace Extracorp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2572.7, "gross_charge": 3958.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000065", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33983", "type": "HCPCS" } ], "description": "Hc Vad Pump Replace Intracorporeal W Bypass", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7189.0, "gross_charge": 11060.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000070", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33999", "type": "HCPCS" } ], "description": "Hc Insert Vad Venous Access Percutaneous W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 913.25, "gross_charge": 1405.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000071", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "0543T", "type": "HCPCS" } ], "description": "Hc Transapical Mitral Valve Repair Transthc Echo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000072", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "0544T", "type": "HCPCS" } ], "description": "Hc Transcath Mitral Valve Annulus Reconstruct W Device Perct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000073", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "0545T", "type": "HCPCS" } ], "description": "Hc Transcath Tricuspid Valve Annulus Reconstruct W Device Perct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000077", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 1 Local Procedure 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2779.4, "gross_charge": 4276.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000078", "type": "CDM" }, { "code": "360", "type": "RC" } ], "description": "Hc Or Level 1 Local Procedure Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 742.95, "gross_charge": 1143.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000079", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33995", "type": "HCPCS" } ], "description": "Hc Insert Right Vad Arterial Access Percutaneous W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 913.25, "gross_charge": 1405.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000080", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "33997", "type": "HCPCS" } ], "description": "Hc Remove Right Vad Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 622.05, "gross_charge": 957.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000081", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "32562", "type": "HCPCS" } ], "description": "Hc Instlj Ch Tube/Cath Agent Fbrnlysis Sbsq Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 854.75, "gross_charge": 1315.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000082", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "61885", "type": "HCPCS" } ], "description": "Hc Ins/Repl Cranl Nstim Pg/Rcvr W 1 Elctr Array", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 39840.45, "gross_charge": 61293.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000083", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "61886", "type": "HCPCS" } ], "description": "Hc Insj/Rplcmt Cranial Neurostim Gener 2/> Eltrds", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94018.6, "gross_charge": 144644.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000084", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "64555", "type": "HCPCS" } ], "description": "Hc Perc Impltj Neurostimulator Eltrd Peripheral Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16120.0, "gross_charge": 24800.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000085", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "64553", "type": "HCPCS" } ], "description": "Hc Perc Impltj Neurostimulator Eltrd Cranial Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19344.0, "gross_charge": 29760.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000086", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "64449", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Lumbar Plexus Cont Infs Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4301.05, "gross_charge": 6617.0, "setting": "both" } ] }, { "code_information": [ { "code": "36000087", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "64568", "type": "HCPCS" } ], "description": "Hc Inc Impltj Crnl Nrv Nstim Eltrds & Pulse Gener", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 56616.3, "gross_charge": 87102.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100001", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10021", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy Wo Img 1St Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 839.15, "gross_charge": 1291.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100003", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10060", "type": "HCPCS" } ], "description": "Hc I And D Abscess Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 605.15, "gross_charge": 931.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100004", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10061", "type": "HCPCS" } ], "description": "Hc I And D Abscess Complicated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1338.35, "gross_charge": 2059.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100005", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10080", "type": "HCPCS" } ], "description": "Hc I And D Pilonidal Cyst Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 893.1, "gross_charge": 1374.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100006", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10120", "type": "HCPCS" } ], "description": "Hc I And D Fb Subq Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 919.1, "gross_charge": 1414.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100007", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10121", "type": "HCPCS" } ], "description": "Hc I And D Fb Subq Complicated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1552.2, "gross_charge": 2388.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100008", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10140", "type": "HCPCS" } ], "description": "Hc I And D Hematoma Seroma Fluid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4457.7, "gross_charge": 6858.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100009", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10160", "type": "HCPCS" } ], "description": "Hc Puncture Aspiration Of Cyst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1232.4, "gross_charge": 1896.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100010", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10180", "type": "HCPCS" } ], "description": "Hc I And D Post Op Infection Comp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9460.1, "gross_charge": 14554.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100011", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11000", "type": "HCPCS" } ], "description": "Hc Debr Skin Up To 10% Body Surface", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 505.05, "gross_charge": 777.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100012", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11010", "type": "HCPCS" } ], "description": "Hc Debride Skin At Fx Site", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1207.05, "gross_charge": 1857.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100013", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11042", "type": "HCPCS" } ], "description": "Hc Debr Subq Tissue <=20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 906.75, "gross_charge": 1395.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100014", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11043", "type": "HCPCS" } ], "description": "Hc Debr Muscle Fascia <=20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1254.5, "gross_charge": 1930.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100015", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11044", "type": "HCPCS" } ], "description": "Hc Debr Bone <=20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3368.95, "gross_charge": 5183.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100016", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11045", "type": "HCPCS" } ], "description": "Hc Debr Subq Tissue Add 20Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 323.7, "gross_charge": 498.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100017", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11046", "type": "HCPCS" } ], "description": "Hc Debr Muscle Fascia Addl 20Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 325.0, "gross_charge": 500.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100018", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11047", "type": "HCPCS" } ], "description": "Hc Debr Bone Addl 20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 371.15, "gross_charge": 571.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100019", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11055", "type": "HCPCS" } ], "description": "Hc Trimming Of Skin Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 351.0, "gross_charge": 540.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100020", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11056", "type": "HCPCS" } ], "description": "Hc Trim Skin Lesions 2-4", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 463.45, "gross_charge": 713.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100021", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11057", "type": "HCPCS" } ], "description": "Hc Trim Skin Lesions >4", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 651.3, "gross_charge": 1002.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100024", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11300", "type": "HCPCS" } ], "description": "Hc Shave Epidermal Dermal Lesion Trunk Arm Leg 0.5Cm Or Less", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 678.6, "gross_charge": 1044.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100025", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11422", "type": "HCPCS" } ], "description": "Hc Exc Ben Lesion S N H F G 1.1-2Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3279.9, "gross_charge": 5046.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100026", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11643", "type": "HCPCS" } ], "description": "Hc Exc Malignant Les Face 2.1-3.0 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3279.9, "gross_charge": 5046.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100027", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11720", "type": "HCPCS" } ], "description": "Hc Debr Nails Up To 5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 364.0, "gross_charge": 560.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100028", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11721", "type": "HCPCS" } ], "description": "Hc Debr Nails 6 Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 546.0, "gross_charge": 840.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100029", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11730", "type": "HCPCS" } ], "description": "Hc Avulsion Nail Plate Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 583.7, "gross_charge": 898.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100030", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11732", "type": "HCPCS" } ], "description": "Hc Avulsion Nail Plate Each Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 354.9, "gross_charge": 546.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100031", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11740", "type": "HCPCS" } ], "description": "Hc Evacuation Subungual Hematoma", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 581.1, "gross_charge": 894.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100032", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11750", "type": "HCPCS" } ], "description": "Hc Excision Nail And Matrix", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 881.4, "gross_charge": 1356.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100033", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11760", "type": "HCPCS" } ], "description": "Hc Repair Nail Bed", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 607.75, "gross_charge": 935.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100034", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11765", "type": "HCPCS" } ], "description": "Hc Excision Nail Fold Toe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 783.25, "gross_charge": 1205.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100035", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11976", "type": "HCPCS" } ], "description": "Hc Removal Contraceptive Capsule", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 759.2, "gross_charge": 1168.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100036", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11981", "type": "HCPCS" } ], "description": "Hc Insertion Contraceptive Capsule", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 759.2, "gross_charge": 1168.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100037", "type": "CDM" }, { "code": "361", "type": "RC" } ], "description": "Hc Lac Repair Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 315.25, "gross_charge": 485.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100038", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "12031", "type": "HCPCS" } ], "description": "Hc Lac Repair Intermediate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 874.25, "gross_charge": 1345.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100040", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "13160", "type": "HCPCS" } ], "description": "Hc Secondary Closure Surg Wound", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1888.9, "gross_charge": 2906.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100043", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15271", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Tal 1St 25 Up To 100 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2120.95, "gross_charge": 3263.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100044", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15272", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Tal Addl 25 Up To 100 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2291.9, "gross_charge": 3526.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100045", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15273", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Tal 1St 100Sq Cm More Than 100Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2811.25, "gross_charge": 4325.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100046", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15274", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Tal Addl 100 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3101.8, "gross_charge": 4772.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100047", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15275", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Hhfg 1St 25 Up To 100 Sqcm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2148.25, "gross_charge": 3305.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100048", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15276", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Hhfg Addl 25 Up To 100 Sqcm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2529.8, "gross_charge": 3892.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100049", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15277", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Hhfg 1St 100=>100Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3614.65, "gross_charge": 5561.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100050", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "15278", "type": "HCPCS" } ], "description": "Hc High Cost Applic Ss Hhfg Addl 100=>100Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3101.8, "gross_charge": 4772.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100051", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "16000", "type": "HCPCS" } ], "description": "Hc Treatment Burn Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 854.1, "gross_charge": 1314.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100052", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "16020", "type": "HCPCS" } ], "description": "Hc Dress Or Debr Burn Wo Anes Small", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 359.45, "gross_charge": 553.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100053", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "16025", "type": "HCPCS" } ], "description": "Hc Dress Or Debr Burn Wo Anes Medium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 738.4, "gross_charge": 1136.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100054", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "16030", "type": "HCPCS" } ], "description": "Hc Dress Or Debr Burn Wo Anes Large", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 955.5, "gross_charge": 1470.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100055", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "17110", "type": "HCPCS" } ], "description": "Hc Destruction Flat Warts <15", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 651.3, "gross_charge": 1002.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100056", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "17250", "type": "HCPCS" } ], "description": "Hc Cauterize Tissue Chemical", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 302.9, "gross_charge": 466.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100057", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "17999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Skin Or Tissue", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1561.3, "gross_charge": 2402.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100058", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19000", "type": "HCPCS" } ], "description": "Hc Aspiration Cyst Breast Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 669.5, "gross_charge": 1030.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100059", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19001", "type": "HCPCS" } ], "description": "Hc Aspiration Cyst Breast Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 371.8, "gross_charge": 572.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100060", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19030", "type": "HCPCS" } ], "description": "Hc Inj Ductogram Or Galactogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2055.3, "gross_charge": 3162.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100060_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19030", "type": "HCPCS" } ], "description": "Hc Inj Ductogram Or Galactogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4110.6, "gross_charge": 6324.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100061", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "19100", "type": "HCPCS" } ], "description": "Hc Bx Breast Percutaneous Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 795.6, "gross_charge": 1224.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100061_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "19100", "type": "HCPCS" } ], "description": "Hc Bx Breast Percutaneous Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1591.2, "gross_charge": 2448.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100072", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "20103", "type": "HCPCS" } ], "description": "Hc Exploration Penetrating Wnd Extremity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 842.4, "gross_charge": 1296.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100073", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20206", "type": "HCPCS" } ], "description": "Hc Biopsy Muscle Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3159.65, "gross_charge": 4861.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100074", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20220", "type": "HCPCS" } ], "description": "Hc Biopsy Bone Superficial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3159.65, "gross_charge": 4861.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100075", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20225", "type": "HCPCS" } ], "description": "Hc Biopsy Bone Deep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3802.5, "gross_charge": 5850.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100076", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20500", "type": "HCPCS" } ], "description": "Hc Injection Sinus Tract Tx", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1855.1, "gross_charge": 2854.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100077", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20501", "type": "HCPCS" } ], "description": "Hc Injection Sinus Tract Dx", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3766.75, "gross_charge": 5795.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100078", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20520", "type": "HCPCS" } ], "description": "Hc Rem Fb Muscle Or Tendon Sheath Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2674.75, "gross_charge": 4115.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100079", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20526", "type": "HCPCS" } ], "description": "Hc Injection Carpal Tunnel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 903.5, "gross_charge": 1390.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100079_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20526", "type": "HCPCS" } ], "description": "Hc Injection Carpal Tunnel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1807.0, "gross_charge": 2780.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100080", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20550", "type": "HCPCS" } ], "description": "Hc Inj Single Tendon Sheath Or Ligament", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 910.0, "gross_charge": 1400.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100080_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20550", "type": "HCPCS" } ], "description": "Hc Inj Single Tendon Sheath Or Ligament", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1820.0, "gross_charge": 2800.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100081", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20551", "type": "HCPCS" } ], "description": "Hc Tendon Origin Insertion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 910.0, "gross_charge": 1400.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100082", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20552", "type": "HCPCS" } ], "description": "Hc Inj Trigger Point 1 Or 2 Muscles", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1095.9, "gross_charge": 1686.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100083", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20553", "type": "HCPCS" } ], "description": "Hc Inj Trigger Point 3 Or More Muscles", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1461.2, "gross_charge": 2248.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100084", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20600", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Small", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1685.45, "gross_charge": 2593.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100084_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20600", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Small", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3370.9, "gross_charge": 5186.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100085", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20605", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Intermediate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1853.15, "gross_charge": 2851.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100085_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20605", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Intermediate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3706.3, "gross_charge": 5702.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100086", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20610", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Large", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2020.85, "gross_charge": 3109.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100086_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20610", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Large", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4041.7, "gross_charge": 6218.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100087", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20612", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Ganglion Cyst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1442.35, "gross_charge": 2219.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100088", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20670", "type": "HCPCS" } ], "description": "Hc Removal Implant Superficial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9554.35, "gross_charge": 14699.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100090", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20982", "type": "HCPCS" } ], "description": "Hc Ct Guided Rf Ablation Bone Tumor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11952.85, "gross_charge": 18389.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100090_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20982", "type": "HCPCS" } ], "description": "Hc Ct Guided Rf Ablation Bone Tumor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 23905.7, "gross_charge": 36778.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100093", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "21550", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Neck Or Thorax", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3088.8, "gross_charge": 4752.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100095", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "21920", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Back Or Flank Sup", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4462.25, "gross_charge": 6865.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100096", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "21925", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Back Or Flank Deep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4462.25, "gross_charge": 6865.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100097", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22510", "type": "HCPCS" } ], "description": "Hc Vertebroplasty Thoracic Percutaneous W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12054.9, "gross_charge": 18546.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100098", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22511", "type": "HCPCS" } ], "description": "Hc Vertebroplasty Lumbar Percutaneous W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12884.3, "gross_charge": 19822.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100099", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22512", "type": "HCPCS" } ], "description": "Hc Vertebroplasty Ea Addl Thor Or Lumb W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6538.35, "gross_charge": 10059.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100100", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22513", "type": "HCPCS" } ], "description": "Hc Kyphoplasty Thoracic W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17314.05, "gross_charge": 26637.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100101", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22514", "type": "HCPCS" } ], "description": "Hc Kyphoplasty Lumbar W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18396.3, "gross_charge": 28302.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100102", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22515", "type": "HCPCS" } ], "description": "Hc Kyphoplasty Ea Addl Thor Or Lumb W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8812.7, "gross_charge": 13558.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100105", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22899", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Spine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9750.65, "gross_charge": 15001.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100106", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "23065", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Shoulder Sup", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4462.25, "gross_charge": 6865.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100106_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "23065", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Shoulder Sup", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8924.5, "gross_charge": 13730.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100107", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "23350", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Shoulder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 925.6, "gross_charge": 1424.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100107_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "23350", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Shoulder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1851.2, "gross_charge": 2848.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100108", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24065", "type": "HCPCS" } ], "description": "Hc Bx Soft Tissue Upper Arm Or Elbow Sup", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2830.1, "gross_charge": 4354.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100108_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24065", "type": "HCPCS" } ], "description": "Hc Bx Soft Tissue Upper Arm Or Elbow Sup", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 5660.2, "gross_charge": 8708.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100109", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24066", "type": "HCPCS" } ], "description": "Hc Bx Soft Tissue Upper Arm Or Elbow Deep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3396.25, "gross_charge": 5225.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100109_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24066", "type": "HCPCS" } ], "description": "Hc Bx Soft Tissue Upper Arm Or Elbow Deep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6792.5, "gross_charge": 10450.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100110", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24220", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Elbow", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1251.9, "gross_charge": 1926.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100110_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24220", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Elbow", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2503.8, "gross_charge": 3852.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100111", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24357", "type": "HCPCS" } ], "description": "Hc Tenotomy Percutaneous Elbow", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3286.4, "gross_charge": 5056.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100111_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "24357", "type": "HCPCS" } ], "description": "Hc Tenotomy Percutaneous Elbow", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6572.8, "gross_charge": 10112.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100112", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "25246", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Wrist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 787.8, "gross_charge": 1212.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100112_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "25246", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Wrist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1575.6, "gross_charge": 2424.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100113", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "26418", "type": "HCPCS" } ], "description": "Hc Repair Hand Tendon Or Flexor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1820.65, "gross_charge": 2801.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100114", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "26605", "type": "HCPCS" } ], "description": "Hc Closed Tx Metacarpal W Manip", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2275.0, "gross_charge": 3500.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100115", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "26756", "type": "HCPCS" } ], "description": "Hc Perc Fixation Finger Or Thumb Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2724.8, "gross_charge": 4192.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100116", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "26951", "type": "HCPCS" } ], "description": "Hc Amputation Finger Or Thumb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5148.0, "gross_charge": 7920.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100117", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27093", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Hip Wo Anes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1509.3, "gross_charge": 2322.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100117_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27093", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Hip Wo Anes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3018.6, "gross_charge": 4644.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100118", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "27306", "type": "HCPCS" } ], "description": "Hc Tenotomy Perc Thigh Tendon/Adctr/Hamstrng Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3446.95, "gross_charge": 5303.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100118_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "27306", "type": "HCPCS" } ], "description": "Hc Tenotomy Perc Thigh Tendon/Adctr/Hamstrng Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6893.9, "gross_charge": 10606.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100119", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27323", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Knee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4462.25, "gross_charge": 6865.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100119_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27323", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Knee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8924.5, "gross_charge": 13730.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100121", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27605", "type": "HCPCS" } ], "description": "Hc Tenotomy Perc Achilles Local Anes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3130.4, "gross_charge": 4816.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100121_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27605", "type": "HCPCS" } ], "description": "Hc Tenotomy Perc Achilles Local Anes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6260.8, "gross_charge": 9632.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100122", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27613", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Lower Extremity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4928.3, "gross_charge": 7582.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100122_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27613", "type": "HCPCS" } ], "description": "Hc Biopsy Soft Tissue Lower Extremity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 9856.6, "gross_charge": 15164.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100123", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27648", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Ankle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 781.95, "gross_charge": 1203.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100123_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27648", "type": "HCPCS" } ], "description": "Hc Inj Arthrography Ankle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1563.9, "gross_charge": 2406.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100124", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28190", "type": "HCPCS" } ], "description": "Hc Removal Foreign Body Foot Subq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 614.9, "gross_charge": 946.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100124_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28190", "type": "HCPCS" } ], "description": "Hc Removal Foreign Body Foot Subq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1229.8, "gross_charge": 1892.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100125", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28230", "type": "HCPCS" } ], "description": "Hc Tenotomy Open Foot Tendon Sgl Or Mult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2399.15, "gross_charge": 3691.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100125_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28230", "type": "HCPCS" } ], "description": "Hc Tenotomy Open Foot Tendon Sgl Or Mult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4798.3, "gross_charge": 7382.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100126", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31575", "type": "HCPCS" } ], "description": "Hc Laryngoscopy Fiberoptic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 522.6, "gross_charge": 804.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100127", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31600", "type": "HCPCS" } ], "description": "Hc Tracheostomy Planned", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2624.05, "gross_charge": 4037.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100128", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31615", "type": "HCPCS" } ], "description": "Hc Bronchoscopy Through Tracheostomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2898.35, "gross_charge": 4459.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100130", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31622", "type": "HCPCS" } ], "description": "Hc Bronchoscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2743.0, "gross_charge": 4220.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100131", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31623", "type": "HCPCS" } ], "description": "Hc Bronchoscopy With Brushing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3910.4, "gross_charge": 6016.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100132", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31624", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Alveolar Lavage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3030.95, "gross_charge": 4663.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100133", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31625", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3530.8, "gross_charge": 5432.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100134", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31626", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Insert Fiducial Markers", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4290.0, "gross_charge": 6600.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100135", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31627", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Computer Assist Nav", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4250.35, "gross_charge": 6539.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100136", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31628", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Transbronch Lung Bx", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3530.8, "gross_charge": 5432.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100137", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31629", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Transbronch Needle Asp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2887.3, "gross_charge": 4442.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100138", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31630", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Dilation Or Fx Repair", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5661.5, "gross_charge": 8710.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100139", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31631", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Insert Trachial Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4458.35, "gross_charge": 6859.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100140", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31632", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Lung Biopsy Ea Addl Lobe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1837.55, "gross_charge": 2827.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100141", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31633", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Needle Bx Ea Addl Lobe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3042.0, "gross_charge": 4680.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100142", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31635", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Removal Foreign Body", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4135.3, "gross_charge": 6362.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100143", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31636", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Insert Bronchial Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4290.0, "gross_charge": 6600.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100144", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31637", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Stent Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 761.8, "gross_charge": 1172.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100145", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31638", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Stent Revision", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4290.0, "gross_charge": 6600.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100146", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31640", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Excision Of Tumor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4585.1, "gross_charge": 7054.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100147", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31641", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Destruction Of Tumor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2799.55, "gross_charge": 4307.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100148", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31643", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Plcmnt Radiation Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3184.35, "gross_charge": 4899.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100149", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31645", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Therap Asp Of Trach Ini", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2887.3, "gross_charge": 4442.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100150", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31646", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Therap Asp Of Trach Sub", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 460.2, "gross_charge": 708.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100151", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31647", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Insert Bronch Valves Ini", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4290.0, "gross_charge": 6600.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100152", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31648", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Rem Bronch Valves Ini", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3640.65, "gross_charge": 5601.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100153", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31649", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Rem Bronch Valves Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2685.8, "gross_charge": 4132.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100154", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31651", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Insert Bronch Valves Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3734.25, "gross_charge": 5745.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100155", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49405", "type": "HCPCS" } ], "description": "Hc Img Guide Fluid Coll Drng By Cath Visceral Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8726.25, "gross_charge": 13425.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100156", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32400", "type": "HCPCS" } ], "description": "Hc Biopsy Pleura Percutaneous Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3247.4, "gross_charge": 4996.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100158", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32550", "type": "HCPCS" } ], "description": "Hc Insert Tunneled Pleural Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7711.6, "gross_charge": 11864.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100159", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32551", "type": "HCPCS" } ], "description": "Hc Thoracostomy Tube Open", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1778.4, "gross_charge": 2736.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100159_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32551", "type": "HCPCS" } ], "description": "Hc Thoracostomy Tube Open", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3556.8, "gross_charge": 5472.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100160", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32552", "type": "HCPCS" } ], "description": "Hc Remove Tunneled Pleural Cath W Cuff", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2425.8, "gross_charge": 3732.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100161", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32554", "type": "HCPCS" } ], "description": "Hc Thoracentesis Wo Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2411.5, "gross_charge": 3710.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100161_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32554", "type": "HCPCS" } ], "description": "Hc Thoracentesis Wo Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4823.0, "gross_charge": 7420.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100162", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32555", "type": "HCPCS" } ], "description": "Hc Thoracentesis W Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3657.55, "gross_charge": 5627.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100162_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32555", "type": "HCPCS" } ], "description": "Hc Thoracentesis W Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7315.1, "gross_charge": 11254.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100163", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32556", "type": "HCPCS" } ], "description": "Hc Perc Pleural Drnge W Ins Catheter Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3523.65, "gross_charge": 5421.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100163_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32556", "type": "HCPCS" } ], "description": "Hc Perc Pleural Drnge W Ins Catheter Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7047.3, "gross_charge": 10842.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100164", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32557", "type": "HCPCS" } ], "description": "Hc Perc Pleural Drnge W Ins Catheter W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5285.8, "gross_charge": 8132.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100164_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32557", "type": "HCPCS" } ], "description": "Hc Perc Pleural Drnge W Ins Catheter W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 10571.6, "gross_charge": 16264.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100165", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32560", "type": "HCPCS" } ], "description": "Hc Chemical Pleurodesis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1773.2, "gross_charge": 2728.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100166", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32998", "type": "HCPCS" } ], "description": "Hc Rf Ablation Pulm Tumor Unilat W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10046.4, "gross_charge": 15456.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100166_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32998", "type": "HCPCS" } ], "description": "Hc Rf Ablation Pulm Tumor Unilat W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 20092.8, "gross_charge": 30912.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100167", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Lungs Or Pleura", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1778.4, "gross_charge": 2736.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100171", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33206", "type": "HCPCS" } ], "description": "Hc Insert Pacer Atrial W Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14160.25, "gross_charge": 21785.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100172", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33207", "type": "HCPCS" } ], "description": "Hc Insert Pacer Ventricular W Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14487.2, "gross_charge": 22288.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100173", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33208", "type": "HCPCS" } ], "description": "Hc Insert Pacer Atrial And Ventricular W Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17323.8, "gross_charge": 26652.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100174", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33210", "type": "HCPCS" } ], "description": "Hc Insert Temporary Pacemaker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7048.6, "gross_charge": 10844.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100175", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33212", "type": "HCPCS" } ], "description": "Hc Insert Pulse Generator Only Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10250.5, "gross_charge": 15770.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100176", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33213", "type": "HCPCS" } ], "description": "Hc Insert Pulse Generator Only Dual", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12077.0, "gross_charge": 18580.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100177", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33214", "type": "HCPCS" } ], "description": "Hc Upgrade Implanted Pacemaker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12077.0, "gross_charge": 18580.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100178", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33215", "type": "HCPCS" } ], "description": "Hc Reposition Previously Implanted Pacer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7794.8, "gross_charge": 11992.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100179", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33216", "type": "HCPCS" } ], "description": "Hc Insertion Transvenous Electrode Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14290.9, "gross_charge": 21986.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100180", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33217", "type": "HCPCS" } ], "description": "Hc Insertion Transvenous Electrode Dual", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15005.25, "gross_charge": 23085.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100181", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33218", "type": "HCPCS" } ], "description": "Hc Repair Transvenous Electrode Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11267.75, "gross_charge": 17335.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100182", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33220", "type": "HCPCS" } ], "description": "Hc Repair Transvenous Electrode Dual", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11981.45, "gross_charge": 18433.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100183", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33221", "type": "HCPCS" } ], "description": "Hc Insert Pacer Pulse Generator Mult Leads", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20169.5, "gross_charge": 31030.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100184", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33222", "type": "HCPCS" } ], "description": "Hc Revision Skin Pocket Pacemaker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6793.8, "gross_charge": 10452.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100185", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33223", "type": "HCPCS" } ], "description": "Hc Revision Skin Pocket Icd", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6793.8, "gross_charge": 10452.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100186", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33224", "type": "HCPCS" } ], "description": "Hc Ins Electrode Prev Placed Icd Or Pacer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22536.15, "gross_charge": 34671.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100187", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33225", "type": "HCPCS" } ], "description": "Hc Ins Electrode At Ins Icd Or Pacer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13338.0, "gross_charge": 20520.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100188", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33226", "type": "HCPCS" } ], "description": "Hc Reposition Previously Impl Cvs Electrode", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7794.8, "gross_charge": 11992.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100189", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33227", "type": "HCPCS" } ], "description": "Hc Rem And Replace Pacer Pulse Gen Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13110.5, "gross_charge": 20170.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100190", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33228", "type": "HCPCS" } ], "description": "Hc Rem And Replace Pacer Pulse Gen Dual", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14504.75, "gross_charge": 22315.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100191", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33229", "type": "HCPCS" } ], "description": "Hc Rem And Replace Pacer Pulse Gen Mult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12139.4, "gross_charge": 18676.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100192", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33230", "type": "HCPCS" } ], "description": "Hc Insert Icd Generator Only Dual", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15481.05, "gross_charge": 23817.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100193", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33231", "type": "HCPCS" } ], "description": "Hc Insert Icd Generator Only Mult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21153.6, "gross_charge": 32544.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100194", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33233", "type": "HCPCS" } ], "description": "Hc Remover Pacer Pulse Generator Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15401.75, "gross_charge": 23695.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100195", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33234", "type": "HCPCS" } ], "description": "Hc Remove Tvs Electrode Sgl Lead System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9014.2, "gross_charge": 13868.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100196", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33235", "type": "HCPCS" } ], "description": "Hc Remove Tvs Electrode Dual Lead System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10175.1, "gross_charge": 15654.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100197", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33240", "type": "HCPCS" } ], "description": "Hc Insertion Icd Generator Only Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16913.0, "gross_charge": 26020.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100198", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33241", "type": "HCPCS" } ], "description": "Hc Remove Icd Generator Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13554.45, "gross_charge": 20853.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100199", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33244", "type": "HCPCS" } ], "description": "Hc Icd Lead Extraction", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13554.45, "gross_charge": 20853.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100200", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33249", "type": "HCPCS" } ], "description": "Hc Ins Or Repl Icd W Pulse Gen Sgl Or Dual", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15613.0, "gross_charge": 24020.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100201", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33262", "type": "HCPCS" } ], "description": "Hc Remove Replace Icd Gen Sgl Lead Sys", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14311.7, "gross_charge": 22018.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100202", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33263", "type": "HCPCS" } ], "description": "Hc Remove Replace Icd Gen Dual Lead Sys", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14109.55, "gross_charge": 21707.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100203", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33264", "type": "HCPCS" } ], "description": "Hc Remove Replace Icd Gen Mult Lead Sys", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13819.0, "gross_charge": 21260.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100206", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33361", "type": "HCPCS" } ], "description": "Hc Tavr Tavi Perc Fem Art Approach", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100207", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33362", "type": "HCPCS" } ], "description": "Hc Tavr Tavi Open Fem Art Approach", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100208", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33363", "type": "HCPCS" } ], "description": "Hc Tavr Tavi Open Axil Art Approach", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100210", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33365", "type": "HCPCS" } ], "description": "Hc Tavr Tavi Transaortic Approach", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34594.3, "gross_charge": 53222.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100211", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33880", "type": "HCPCS" } ], "description": "Hc Endovasc Rep Descend Thorac Aorta Subclav", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2315.95, "gross_charge": 3563.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100212", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33881", "type": "HCPCS" } ], "description": "Hc Endovasc Rep Descend Thorac Aorta No Subcl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2315.95, "gross_charge": 3563.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100213", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33883", "type": "HCPCS" } ], "description": "Hc Plcmnt Prox Ext Prosthesis Rpr Desc Aorta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 848.25, "gross_charge": 1305.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100214", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33884", "type": "HCPCS" } ], "description": "Hc Plcmnt Prox Ext Prosthesis Rpr Desc Aorta Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 848.25, "gross_charge": 1305.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100215", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33886", "type": "HCPCS" } ], "description": "Hc Plcmnt Dist Ext Prosthesis Delayd After Rpr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2315.95, "gross_charge": 3563.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100216", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Cardiac Surgery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 942.5, "gross_charge": 1450.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100222", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34201", "type": "HCPCS" } ], "description": "Hc Embolectomy Fem Pop Aortoiliac Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4340.05, "gross_charge": 6677.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100222_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34201", "type": "HCPCS" } ], "description": "Hc Embolectomy Fem Pop Aortoiliac Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8680.1, "gross_charge": 13354.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100244", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36000", "type": "HCPCS" } ], "description": "Hc Intro Needle Or Intracatheter Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 687.05, "gross_charge": 1057.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100245", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36002", "type": "HCPCS" } ], "description": "Hc Injection Thrombin Pseudoaneurysm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2995.2, "gross_charge": 4608.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100245_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36002", "type": "HCPCS" } ], "description": "Hc Injection Thrombin Pseudoaneurysm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 5990.4, "gross_charge": 9216.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100246", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36005", "type": "HCPCS" } ], "description": "Hc Injection Extremity Venogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1901.25, "gross_charge": 2925.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100246_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36005", "type": "HCPCS" } ], "description": "Hc Injection Extremity Venogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3802.5, "gross_charge": 5850.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100247", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36010", "type": "HCPCS" } ], "description": "Hc Introduction Catheter Inf Or Sup Vena Cava", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1248.0, "gross_charge": 1920.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100247_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36010", "type": "HCPCS" } ], "description": "Hc Introduction Catheter Inf Or Sup Vena Cava", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2496.0, "gross_charge": 3840.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100248", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36011", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Venous 1St Order", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 993.2, "gross_charge": 1528.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100248_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36011", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Venous 1St Order", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1986.4, "gross_charge": 3056.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100249", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36012", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Venous 2Nd Order", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1006.85, "gross_charge": 1549.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100249_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36012", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Venous 2Nd Order", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2013.7, "gross_charge": 3098.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100250", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36013", "type": "HCPCS" } ], "description": "Hc Intro Catheter Rt Heart Or Main Pulm Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 347.75, "gross_charge": 535.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100251", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36014", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Rt Or Lt Pulm Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1073.8, "gross_charge": 1652.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100251_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36014", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Rt Or Lt Pulm Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2147.6, "gross_charge": 3304.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100252", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36015", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Seg Or Subseg Pulm Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 909.35, "gross_charge": 1399.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100252_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36015", "type": "HCPCS" } ], "description": "Hc Sel Cath Placement Seg Or Subseg Pulm Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1818.7, "gross_charge": 2798.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100254", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36140", "type": "HCPCS" } ], "description": "Hc Intro Needle Or Cath Extremity Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2086.5, "gross_charge": 3210.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100257", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36160", "type": "HCPCS" } ], "description": "Hc Intro Needle Or Cath Aorta Translumbar", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1239.55, "gross_charge": 1907.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100258", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36200", "type": "HCPCS" } ], "description": "Hc Introduction Catheter Aorta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2086.5, "gross_charge": 3210.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100258_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36200", "type": "HCPCS" } ], "description": "Hc Introduction Catheter Aorta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4173.0, "gross_charge": 6420.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100259", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36215", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Thrc Brch Cphlc Brnch 1St Ord", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1553.5, "gross_charge": 2390.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100260", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36216", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Thrc Brch Cphlc Brnch 2Nd Ord 1St", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1453.4, "gross_charge": 2236.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100261", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36217", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Thrc Brch Cphlc Brnch 3Rd+ Ord", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1397.5, "gross_charge": 2150.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100262", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36218", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Thrc Brch Cphlc Brnch Addl 2Nd Or 3Rd", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1274.65, "gross_charge": 1961.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100263", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36221", "type": "HCPCS" } ], "description": "Hc Nonsel Cath Thor Aorta Angio Intr Xtrcranial Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3731.0, "gross_charge": 5740.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100264", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36222", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Cmn Crtd Angio Xtrcrnl Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10132.2, "gross_charge": 15588.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100264_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36222", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Cmn Crtd Angio Xtrcrnl Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 20264.4, "gross_charge": 31176.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100265", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36223", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Cmn Crtd Angio Intrcrnl Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6993.35, "gross_charge": 10759.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100265_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36223", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Cmn Crtd Angio Intrcrnl Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 13986.7, "gross_charge": 21518.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100266", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36224", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Int Crtd Angio Intrcrnl Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9080.5, "gross_charge": 13970.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100266_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36224", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Int Crtd Angio Intrcrnl Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 18161.0, "gross_charge": 27940.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100267", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36225", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Subclv Art Angio Vertebral Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3359.2, "gross_charge": 5168.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100267_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36225", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Subclv Art Angio Vertebral Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6718.4, "gross_charge": 10336.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100268", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36226", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Vertebral Art Angio Vertebral Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3359.2, "gross_charge": 5168.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100268_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36226", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Vertebral Art Angio Vertebral Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6718.4, "gross_charge": 10336.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100269", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36227", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Xtrnl Crtd Art Angio Xtrnl Crtd Circ", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1525.55, "gross_charge": 2347.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100270", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36228", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Intrcrnl Branch Angio Ntrnl Crtd Vert", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1788.8, "gross_charge": 2752.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100271", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36245", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Ea 1St Order Abd Pel Le Art Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1355.25, "gross_charge": 2085.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100271_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36245", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Ea 1St Order Abd Pel Le Art Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2710.5, "gross_charge": 4170.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100272", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36246", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc 2Nd Order Abd Pel Le Art Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1363.7, "gross_charge": 2098.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100272_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36246", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc 2Nd Order Abd Pel Le Art Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2727.4, "gross_charge": 4196.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100273", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36247", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc 3Rd+ Order Abd Pel Le Art Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1363.7, "gross_charge": 2098.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100273_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36247", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc 3Rd+ Order Abd Pel Le Art Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2727.4, "gross_charge": 4196.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100274", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36248", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc Ea 2Nd+ Order Abd Pel Le Art Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1305.2, "gross_charge": 2008.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100275", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36251", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc 1St Order Renal Artery Uni W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10729.55, "gross_charge": 16507.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100276", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36252", "type": "HCPCS" } ], "description": "Hc Sel Cath Plc 1St Order Renal Artery Bil W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12677.6, "gross_charge": 19504.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100277", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36253", "type": "HCPCS" } ], "description": "Hc Ins Cath 2Nd+ Order Ren Art Uni W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7090.85, "gross_charge": 10909.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100278", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36254", "type": "HCPCS" } ], "description": "Hc Ins Cath 2Nd+ Order Ren Art Bil W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9808.5, "gross_charge": 15090.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100279", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36299", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Vascular Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 309.4, "gross_charge": 476.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100280", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36468", "type": "HCPCS" } ], "description": "Hc Inj Sclerosant For Spider Veins Limb Or Trunk", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 418.6, "gross_charge": 644.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100281", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36470", "type": "HCPCS" } ], "description": "Hc Inj Sclerosing Soln Single Incompetent Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 462.8, "gross_charge": 712.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100281_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36470", "type": "HCPCS" } ], "description": "Hc Inj Sclerosing Soln Single Incompetent Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 925.6, "gross_charge": 1424.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100282", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36471", "type": "HCPCS" } ], "description": "Hc Inj Sclerosing Soln Mult Incompetent Veins Same Leg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 462.8, "gross_charge": 712.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100282_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36471", "type": "HCPCS" } ], "description": "Hc Inj Sclerosing Soln Mult Incompetent Veins Same Leg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 925.6, "gross_charge": 1424.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100283", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36475", "type": "HCPCS" } ], "description": "Hc Endovenous Ablation Ext Rf 1St Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6113.9, "gross_charge": 9406.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100283_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36475", "type": "HCPCS" } ], "description": "Hc Endovenous Ablation Ext Rf 1St Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 12227.8, "gross_charge": 18812.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100284", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36476", "type": "HCPCS" } ], "description": "Hc Endovenous Ablation Ext Rf 2Nd+ Veins", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3708.9, "gross_charge": 5706.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100285", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36478", "type": "HCPCS" } ], "description": "Hc Endovenous Ablation Ext Laser 1St Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6113.9, "gross_charge": 9406.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100285_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36478", "type": "HCPCS" } ], "description": "Hc Endovenous Ablation Ext Laser 1St Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 12227.8, "gross_charge": 18812.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100286", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36479", "type": "HCPCS" } ], "description": "Hc Endovenous Ablation Ext Laser 2Nd+ Veins", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3708.9, "gross_charge": 5706.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100287", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36481", "type": "HCPCS" } ], "description": "Hc Perc Portal Vein Catheterization", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 488.8, "gross_charge": 752.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100288", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36500", "type": "HCPCS" } ], "description": "Hc Cath Venous Sel Organ Blood Sample", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 328.9, "gross_charge": 506.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100289", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36510", "type": "HCPCS" } ], "description": "Hc Cath Umbilical Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 335.4, "gross_charge": 516.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100290", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36511", "type": "HCPCS" } ], "description": "Hc Therapeutic Apheresis For Wbc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2945.8, "gross_charge": 4532.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100291", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36512", "type": "HCPCS" } ], "description": "Hc Therapeutic Apheresis For Rbc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5266.3, "gross_charge": 8102.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100292", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36513", "type": "HCPCS" } ], "description": "Hc Therapeutic Apheresis For Platelets", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4909.45, "gross_charge": 7553.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100293", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36514", "type": "HCPCS" } ], "description": "Hc Therapeutic Pheresis For Plasma", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5428.8, "gross_charge": 8352.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100294", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36556", "type": "HCPCS" } ], "description": "Hc Insert Cvc Nontunneled Age 5 Or Older", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2202.85, "gross_charge": 3389.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100295", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36558", "type": "HCPCS" } ], "description": "Hc Insert Cvc Tunneled Age 5 Or Older", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7020.0, "gross_charge": 10800.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100295_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36558", "type": "HCPCS" } ], "description": "Hc Insert Cvc Tunneled Age 5 Or Older", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 14040.0, "gross_charge": 21600.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100296", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36561", "type": "HCPCS" } ], "description": "Hc Insert Cva Device W Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7488.0, "gross_charge": 11520.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100296_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36561", "type": "HCPCS" } ], "description": "Hc Insert Cva Device W Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 14976.0, "gross_charge": 23040.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100297", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36565", "type": "HCPCS" } ], "description": "Hc Insert Cva 2 Caths Wo Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7956.0, "gross_charge": 12240.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100297_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36565", "type": "HCPCS" } ], "description": "Hc Insert Cva 2 Caths Wo Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 15912.0, "gross_charge": 24480.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100298", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36566", "type": "HCPCS" } ], "description": "Hc Insert Cva 2 Caths W Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8424.0, "gross_charge": 12960.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100298_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36566", "type": "HCPCS" } ], "description": "Hc Insert Cva 2 Caths W Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 16848.0, "gross_charge": 25920.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100299", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36569", "type": "HCPCS" } ], "description": "Hc Insert Picc Wo Sq Port Wo Imaging Guidance Age 5 Or Older", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2202.85, "gross_charge": 3389.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100300", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36575", "type": "HCPCS" } ], "description": "Hc Repair Cva Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4283.5, "gross_charge": 6590.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100301", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36576", "type": "HCPCS" } ], "description": "Hc Repair Cva Device W Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5278.0, "gross_charge": 8120.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100302", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36578", "type": "HCPCS" } ], "description": "Hc Replace Cath Cva Device W Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8889.4, "gross_charge": 13676.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100303", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36580", "type": "HCPCS" } ], "description": "Hc Replace Non-Tunneled Cvc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2202.85, "gross_charge": 3389.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100304", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36581", "type": "HCPCS" } ], "description": "Hc Replace Tunneled Cvc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6552.0, "gross_charge": 10080.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100305", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36582", "type": "HCPCS" } ], "description": "Hc Repl Tunneled Cva Dev W Sq Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7020.0, "gross_charge": 10800.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100306", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36584", "type": "HCPCS" } ], "description": "Hc Replace Picc Wo Sq Port Incl All Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3197.35, "gross_charge": 4919.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100307", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36589", "type": "HCPCS" } ], "description": "Hc Rem Tun Cvc Wo Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3201.9, "gross_charge": 4926.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100308", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36590", "type": "HCPCS" } ], "description": "Hc Rem Implant Access Port Sub", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4644.9, "gross_charge": 7146.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100309", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "36591", "type": "HCPCS" } ], "description": "Hc Collect Bld Spec Impl Vad", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 516.1, "gross_charge": 794.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100310", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "36592", "type": "HCPCS" } ], "description": "Hc Collect Spec Picc Or Cvc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100311", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36593", "type": "HCPCS" } ], "description": "Hc Declot Cath Or Vad By Thrombolytic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1906.45, "gross_charge": 2933.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100312", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36595", "type": "HCPCS" } ], "description": "Hc Rem Pericath Obstructive Material", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3434.6, "gross_charge": 5284.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100313", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36596", "type": "HCPCS" } ], "description": "Hc Rem Intraluminal Obscructive Material", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1550.9, "gross_charge": 2386.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100314", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36597", "type": "HCPCS" } ], "description": "Hc Reposition Cvc W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3981.9, "gross_charge": 6126.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100315", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36598", "type": "HCPCS" } ], "description": "Hc Contrast Inj Vad W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2245.75, "gross_charge": 3455.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100315_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36598", "type": "HCPCS" } ], "description": "Hc Contrast Inj Vad W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4491.5, "gross_charge": 6910.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100316", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "36600", "type": "HCPCS" } ], "description": "Hc Abg Puncture", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 213.85, "gross_charge": 329.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100317", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36620", "type": "HCPCS" } ], "description": "Hc Insert Arterial Cath Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 649.35, "gross_charge": 999.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100326", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37182", "type": "HCPCS" } ], "description": "Hc Insertion Of Tips", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24617.45, "gross_charge": 37873.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100327", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37183", "type": "HCPCS" } ], "description": "Hc Revision Of Tips", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18506.8, "gross_charge": 28472.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100328", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37184", "type": "HCPCS" } ], "description": "Hc Art Mech Throm (Non Cor) 1St Ves", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12360.4, "gross_charge": 19016.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100328_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37184", "type": "HCPCS" } ], "description": "Hc Art Mech Throm (Non Cor) 1St Ves", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 24720.8, "gross_charge": 38032.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100329", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37185", "type": "HCPCS" } ], "description": "Hc Art Mech Throm (Non Cor)Addl Ves", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13332.8, "gross_charge": 20512.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100330", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37186", "type": "HCPCS" } ], "description": "Hc Art Mech Throm (Non Cor) Secondary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15101.45, "gross_charge": 23233.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100331", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37187", "type": "HCPCS" } ], "description": "Hc Ven Mechanical Thrombectomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12671.75, "gross_charge": 19495.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100331_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37187", "type": "HCPCS" } ], "description": "Hc Ven Mechanical Thrombectomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 25343.5, "gross_charge": 38990.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100332", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37188", "type": "HCPCS" } ], "description": "Hc Ven Mechanical Thromb Repeat Tx", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8027.5, "gross_charge": 12350.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100332_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37188", "type": "HCPCS" } ], "description": "Hc Ven Mechanical Thromb Repeat Tx", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 16055.0, "gross_charge": 24700.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100333", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37191", "type": "HCPCS" } ], "description": "Hc Insert Ivc Filter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12535.9, "gross_charge": 19286.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100334", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37192", "type": "HCPCS" } ], "description": "Hc Reposition Ivc Filter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4702.1, "gross_charge": 7234.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100335", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37193", "type": "HCPCS" } ], "description": "Hc Remove Ivc Filter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8752.9, "gross_charge": 13466.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100336", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37195", "type": "HCPCS" } ], "description": "Hc Thrombolysis Cerebral Iv Infusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 373.75, "gross_charge": 575.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100337", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37197", "type": "HCPCS" } ], "description": "Hc Transcath Rtrvl Intrvas Fb W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7001.8, "gross_charge": 10772.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100338", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37200", "type": "HCPCS" } ], "description": "Hc Transcatheter Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9382.1, "gross_charge": 14434.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100346", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37211", "type": "HCPCS" } ], "description": "Hc Trnscth Tx Thrmb Art Init Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31678.4, "gross_charge": 48736.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100346_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37211", "type": "HCPCS" } ], "description": "Hc Trnscth Tx Thrmb Art Init Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 63356.8, "gross_charge": 97472.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100347", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37212", "type": "HCPCS" } ], "description": "Hc Trnscth Tx Thrmb Ven Init Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23951.2, "gross_charge": 36848.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100347_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37212", "type": "HCPCS" } ], "description": "Hc Trnscth Tx Thrmb Ven Init Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 47902.4, "gross_charge": 73696.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100348", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37213", "type": "HCPCS" } ], "description": "Hc Trnscth Tx Thrmb Subq Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25662.0, "gross_charge": 39480.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100349", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37214", "type": "HCPCS" } ], "description": "Hc Trnscth Tx Thrmb Cessation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24507.6, "gross_charge": 37704.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100350", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37215", "type": "HCPCS" } ], "description": "Hc Transcath Stent Cca W Eps", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26497.9, "gross_charge": 40766.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100350_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37215", "type": "HCPCS" } ], "description": "Hc Transcath Stent Cca W Eps", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 52995.8, "gross_charge": 81532.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100351", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37216", "type": "HCPCS" } ], "description": "Hc Transcath Stent Cca Wo Eps", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12039.95, "gross_charge": 18523.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100352", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37220", "type": "HCPCS" } ], "description": "Hc Revasc Endo Iliac Init W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13514.15, "gross_charge": 20791.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100352_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37220", "type": "HCPCS" } ], "description": "Hc Revasc Endo Iliac Init W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 27028.3, "gross_charge": 41582.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100353", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37221", "type": "HCPCS" } ], "description": "Hc Revasc/Endo Iliac W Stnt W/Wo Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13958.1, "gross_charge": 21474.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100353_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37221", "type": "HCPCS" } ], "description": "Hc Revasc/Endo Iliac W Stnt W/Wo Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 27916.2, "gross_charge": 42948.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100354", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37222", "type": "HCPCS" } ], "description": "Hc Iliac Ea Addl Ipsilat Vsl W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3543.15, "gross_charge": 5451.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100355", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37223", "type": "HCPCS" } ], "description": "Hc Iliac Ea Adl Ipsil Vsl W Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4078.75, "gross_charge": 6275.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100356", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37224", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13735.15, "gross_charge": 21131.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100356_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37224", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 27470.3, "gross_charge": 42262.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100357", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37225", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Atherectomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16444.35, "gross_charge": 25299.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100357_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37225", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Atherectomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 32888.7, "gross_charge": 50598.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100358", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37226", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14530.75, "gross_charge": 22355.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100358_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37226", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 29061.5, "gross_charge": 44710.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100359", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37227", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Stnt&Atherec", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18271.5, "gross_charge": 28110.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100359_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37227", "type": "HCPCS" } ], "description": "Hc Revasc Endo Fempop W Stnt&Atherec", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 36543.0, "gross_charge": 56220.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100360", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37228", "type": "HCPCS" } ], "description": "Hc Revasc Endo Tibiopero W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14368.25, "gross_charge": 22105.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100360_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37228", "type": "HCPCS" } ], "description": "Hc Revasc Endo Tibiopero W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 28736.5, "gross_charge": 44210.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100361", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37229", "type": "HCPCS" } ], "description": "Hc Revasc Endo Tibiopero W Atherectm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14459.25, "gross_charge": 22245.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100361_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37229", "type": "HCPCS" } ], "description": "Hc Revasc Endo Tibiopero W Atherectm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 28918.5, "gross_charge": 44490.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100362", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37230", "type": "HCPCS" } ], "description": "Hc Revasc Endo Tibiopero W Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15120.3, "gross_charge": 23262.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100362_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37230", "type": "HCPCS" } ], "description": "Hc Revasc Endo Tibiopero W Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 30240.6, "gross_charge": 46524.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100363", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37231", "type": "HCPCS" } ], "description": "Hc Revasc/Endo Tibioper W Stnt&Ather", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22380.8, "gross_charge": 34432.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100363_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37231", "type": "HCPCS" } ], "description": "Hc Revasc/Endo Tibioper W Stnt&Ather", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 44761.6, "gross_charge": 68864.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100364", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37232", "type": "HCPCS" } ], "description": "Hc Tibiopero Ea Addl W Pta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3294.2, "gross_charge": 5068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100365", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37233", "type": "HCPCS" } ], "description": "Hc Tibiopero W Atherectmy Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3294.2, "gross_charge": 5068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100366", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37234", "type": "HCPCS" } ], "description": "Hc Tibiopero W Stent Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3294.2, "gross_charge": 5068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100367", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37235", "type": "HCPCS" } ], "description": "Hc Tibiopero W Stnt&Atherec Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3294.2, "gross_charge": 5068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100371", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37765", "type": "HCPCS" } ], "description": "Hc Stab Phleb Veins 1 Leg 10-20 Incis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9250.8, "gross_charge": 14232.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100371_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37765", "type": "HCPCS" } ], "description": "Hc Stab Phleb Veins 1 Leg 10-20 Incis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 18501.6, "gross_charge": 28464.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100372", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37799", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Vascular Surg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 407.55, "gross_charge": 627.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100373", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38200", "type": "HCPCS" } ], "description": "Hc Inj Splenoportogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 804.7, "gross_charge": 1238.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100374", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38220", "type": "HCPCS" } ], "description": "Hc Bone Marrow Diagnostic Aspiration(S) Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3066.05, "gross_charge": 4717.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100374_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38220", "type": "HCPCS" } ], "description": "Hc Bone Marrow Diagnostic Aspiration(S) Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6132.1, "gross_charge": 9434.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100375", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38221", "type": "HCPCS" } ], "description": "Hc Bone Marrow Diagnostic Biopsy(Ies) Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3220.1, "gross_charge": 4954.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100375_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38221", "type": "HCPCS" } ], "description": "Hc Bone Marrow Diagnostic Biopsy(Ies) Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6440.2, "gross_charge": 9908.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100376", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38505", "type": "HCPCS" } ], "description": "Hc Biopsy Lymph Node Superficial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2580.5, "gross_charge": 3970.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100376_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38505", "type": "HCPCS" } ], "description": "Hc Biopsy Lymph Node Superficial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 5161.0, "gross_charge": 7940.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100377", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38790", "type": "HCPCS" } ], "description": "Hc Injection For Lymphangiography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1323.4, "gross_charge": 2036.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100377_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38790", "type": "HCPCS" } ], "description": "Hc Injection For Lymphangiography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2646.8, "gross_charge": 4072.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100378", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38792", "type": "HCPCS" } ], "description": "Hc Injection Tracer For Sentinel Node Id", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1323.4, "gross_charge": 2036.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100378_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38792", "type": "HCPCS" } ], "description": "Hc Injection Tracer For Sentinel Node Id", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2646.8, "gross_charge": 4072.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100380", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "41899", "type": "HCPCS" } ], "description": "Hc Unlisted Dentoalvolar Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 720.2, "gross_charge": 1108.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100381", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "42400", "type": "HCPCS" } ], "description": "Hc Biopsy Salivary Gland Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1712.75, "gross_charge": 2635.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100382", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "42550", "type": "HCPCS" } ], "description": "Hc Injection For Sialogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2510.95, "gross_charge": 3863.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100383", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "42660", "type": "HCPCS" } ], "description": "Hc Dil Cath Salivary Duct W Wo Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 330.85, "gross_charge": 509.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100384", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "43752", "type": "HCPCS" } ], "description": "Hc Ng Tube Placement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2005.25, "gross_charge": 3085.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100385", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "43761", "type": "HCPCS" } ], "description": "Hc Reposition Oro Or Naso Gastric Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2005.25, "gross_charge": 3085.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100388", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "44500", "type": "HCPCS" } ], "description": "Hc Introduction Long Gi Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1372.15, "gross_charge": 2111.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100390", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47000", "type": "HCPCS" } ], "description": "Hc Biopsy Liver Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4028.05, "gross_charge": 6197.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100391", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47001", "type": "HCPCS" } ], "description": "Hc Biopsy Liver W Other Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1204.45, "gross_charge": 1853.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100394", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47382", "type": "HCPCS" } ], "description": "Hc Rf Ablation Liver Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10940.8, "gross_charge": 16832.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100396", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47490", "type": "HCPCS" } ], "description": "Hc Cholecystostomy W Img And Cath Plcmnt Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6719.05, "gross_charge": 10337.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100404", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47553", "type": "HCPCS" } ], "description": "Hc Biliary Endo Perc With Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4251.0, "gross_charge": 6540.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100409", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Biliary Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3772.6, "gross_charge": 5804.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100410", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "48102", "type": "HCPCS" } ], "description": "Hc Biopsy Pancreas Perc Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3187.6, "gross_charge": 4904.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100413", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49406", "type": "HCPCS" } ], "description": "Hc Img Guide Fluid Coll Drng By Cath Peri Or Retro Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8492.9, "gross_charge": 13066.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100418", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49082", "type": "HCPCS" } ], "description": "Hc Abdominal Paracentesis Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2902.25, "gross_charge": 4465.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100419", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49083", "type": "HCPCS" } ], "description": "Hc Abdominal Paracentesis W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3368.95, "gross_charge": 5183.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100420", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49180", "type": "HCPCS" } ], "description": "Hc Biopsy Abd Or Retroperitoneal Needle Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4883.45, "gross_charge": 7513.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100424", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49400", "type": "HCPCS" } ], "description": "Hc Injection Air Or Contrast Peritoneal Cavity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5023.2, "gross_charge": 7728.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100425", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49418", "type": "HCPCS" } ], "description": "Hc Insert Tunneled Intraperitoneal Cath W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10476.7, "gross_charge": 16118.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100426", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49419", "type": "HCPCS" } ], "description": "Hc Insert Tunneled Intraperitoneal Cath Subq Port", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9750.65, "gross_charge": 15001.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100427", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49421", "type": "HCPCS" } ], "description": "Hc Insert Tunneled Intraperitoneal Cath Open", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10476.7, "gross_charge": 16118.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100428", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49422", "type": "HCPCS" } ], "description": "Hc Remove Tunneled Intraperitoneal Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4789.2, "gross_charge": 7368.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100429", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49423", "type": "HCPCS" } ], "description": "Hc Drainage Catheter Exchange W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1994.2, "gross_charge": 3068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100430", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49424", "type": "HCPCS" } ], "description": "Hc Inject Contrast Abscess Or Cyst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 624.0, "gross_charge": 960.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100431", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49427", "type": "HCPCS" } ], "description": "Hc Inject Contrast Shuntogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3643.9, "gross_charge": 5606.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100432", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49440", "type": "HCPCS" } ], "description": "Hc Place G Tube Percutaneous W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6564.35, "gross_charge": 10099.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100433", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49441", "type": "HCPCS" } ], "description": "Hc Place J Tube Percutaneous W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6564.35, "gross_charge": 10099.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100434", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49446", "type": "HCPCS" } ], "description": "Hc Convert G To Gj Tube W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6473.35, "gross_charge": 9959.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100435", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49450", "type": "HCPCS" } ], "description": "Hc Replace G Tube W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4375.8, "gross_charge": 6732.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100436", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49451", "type": "HCPCS" } ], "description": "Hc Replace J Tube W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5250.7, "gross_charge": 8078.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100437", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49452", "type": "HCPCS" } ], "description": "Hc Replace G J Tube W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5250.7, "gross_charge": 8078.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100438", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "49465", "type": "HCPCS" } ], "description": "Hc Inject Contrast Existing G Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4606.55, "gross_charge": 7087.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100439", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Abd Peritoneum Omentum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5261.1, "gross_charge": 8094.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100441", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50080", "type": "HCPCS" } ], "description": "Hc Nephrostolithotomy Up To 2Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8589.75, "gross_charge": 13215.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100441_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50080", "type": "HCPCS" } ], "description": "Hc Nephrostolithotomy Up To 2Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 17179.5, "gross_charge": 26430.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100442", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50200", "type": "HCPCS" } ], "description": "Hc Biopsy Renal Percutaneous Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4176.25, "gross_charge": 6425.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100442_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50200", "type": "HCPCS" } ], "description": "Hc Biopsy Renal Percutaneous Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8352.5, "gross_charge": 12850.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100443", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50382", "type": "HCPCS" } ], "description": "Hc Rem And Repl Ureteral Stent Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7608.9, "gross_charge": 11706.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100443_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50382", "type": "HCPCS" } ], "description": "Hc Rem And Repl Ureteral Stent Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 15217.8, "gross_charge": 23412.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100444", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50384", "type": "HCPCS" } ], "description": "Hc Rem Ureteral Stent Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8030.1, "gross_charge": 12354.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100444_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50384", "type": "HCPCS" } ], "description": "Hc Rem Ureteral Stent Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 16060.2, "gross_charge": 24708.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100445", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50385", "type": "HCPCS" } ], "description": "Hc Rem And Repl Ureteral Stent Transurethral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7769.45, "gross_charge": 11953.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100445_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50385", "type": "HCPCS" } ], "description": "Hc Rem And Repl Ureteral Stent Transurethral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 15538.9, "gross_charge": 23906.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100446", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50386", "type": "HCPCS" } ], "description": "Hc Rem Ureteral Stent Transurethral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4792.45, "gross_charge": 7373.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100446_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50386", "type": "HCPCS" } ], "description": "Hc Rem Ureteral Stent Transurethral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 9584.9, "gross_charge": 14746.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100447", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50387", "type": "HCPCS" } ], "description": "Hc Rem And Repl Transnephric Ureteral Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7769.45, "gross_charge": 11953.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100447_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50387", "type": "HCPCS" } ], "description": "Hc Rem And Repl Transnephric Ureteral Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 15538.9, "gross_charge": 23906.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100448", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50389", "type": "HCPCS" } ], "description": "Hc Remove Nephrostomy Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1964.3, "gross_charge": 3022.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100448_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50389", "type": "HCPCS" } ], "description": "Hc Remove Nephrostomy Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3928.6, "gross_charge": 6044.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100449", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50390", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Renal Cyst Or Pelvis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3821.35, "gross_charge": 5879.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100449_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50390", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Renal Cyst Or Pelvis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7642.7, "gross_charge": 11758.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100450", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50391", "type": "HCPCS" } ], "description": "Hc Instill Chemo Kidney Via Nephrostomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 730.6, "gross_charge": 1124.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100450_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50391", "type": "HCPCS" } ], "description": "Hc Instill Chemo Kidney Via Nephrostomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1461.2, "gross_charge": 2248.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100455", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50396", "type": "HCPCS" } ], "description": "Hc Manometric Study Thru Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9429.55, "gross_charge": 14507.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100455_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50396", "type": "HCPCS" } ], "description": "Hc Manometric Study Thru Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 18859.1, "gross_charge": 29014.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100458", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50592", "type": "HCPCS" } ], "description": "Hc Rf Ablation Renal Tumors Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9144.2, "gross_charge": 14068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100458_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50592", "type": "HCPCS" } ], "description": "Hc Rf Ablation Renal Tumors Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 18288.4, "gross_charge": 28136.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100459", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50593", "type": "HCPCS" } ], "description": "Hc Cryoablation Renal Tumor Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9434.1, "gross_charge": 14514.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100459_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50593", "type": "HCPCS" } ], "description": "Hc Cryoablation Renal Tumor Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 18868.2, "gross_charge": 29028.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100460", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50684", "type": "HCPCS" } ], "description": "Hc Inj For Ureterography Or Ureteropyelography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1357.2, "gross_charge": 2088.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100460_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50684", "type": "HCPCS" } ], "description": "Hc Inj For Ureterography Or Ureteropyelography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2714.4, "gross_charge": 4176.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100461", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50688", "type": "HCPCS" } ], "description": "Hc Change Nephroureteral Tube Or Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3710.2, "gross_charge": 5708.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100462", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50690", "type": "HCPCS" } ], "description": "Hc Injection Ileal Conduit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2510.95, "gross_charge": 3863.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100463", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51040", "type": "HCPCS" } ], "description": "Hc Cystostomy Cystotomy W Drainage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8849.1, "gross_charge": 13614.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100464", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51600", "type": "HCPCS" } ], "description": "Hc Inj Cystography Or Voiding Urethrocysto", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2481.7, "gross_charge": 3818.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100465", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51610", "type": "HCPCS" } ], "description": "Hc Inj For Retrograde Urethrocystography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2223.0, "gross_charge": 3420.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100466", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51700", "type": "HCPCS" } ], "description": "Hc Irrig Bladder Simple And Or Instillation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1034.15, "gross_charge": 1591.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100467", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51701", "type": "HCPCS" } ], "description": "Hc Insertion Catheter Straight", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 484.25, "gross_charge": 745.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100468", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51702", "type": "HCPCS" } ], "description": "Hc Insertion Catheter Foley", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 592.8, "gross_charge": 912.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100469", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51705", "type": "HCPCS" } ], "description": "Hc Change Cysto Tube Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3097.9, "gross_charge": 4766.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100470", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51710", "type": "HCPCS" } ], "description": "Hc Change Cysto Tube Complicated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9144.2, "gross_charge": 14068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100471", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "52000", "type": "HCPCS" } ], "description": "Hc Cystourethroscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2629.25, "gross_charge": 4045.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100472", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "52001", "type": "HCPCS" } ], "description": "Hc Cystourethroscopy W Irrigation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3019.25, "gross_charge": 4645.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100474", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "52310", "type": "HCPCS" } ], "description": "Hc Cysto W Removal Fb Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4523.35, "gross_charge": 6959.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100476", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "52332", "type": "HCPCS" } ], "description": "Hc Cystoscopy W Ins Ureteral Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4999.15, "gross_charge": 7691.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100476_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "52332", "type": "HCPCS" } ], "description": "Hc Cystoscopy W Ins Ureteral Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 9998.3, "gross_charge": 15382.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100478", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "52351", "type": "HCPCS" } ], "description": "Hc Cystoscopy W Ureteroscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4702.1, "gross_charge": 7234.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100480", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "53899", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Urinary System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2290.6, "gross_charge": 3524.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100481", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "54150", "type": "HCPCS" } ], "description": "Hc Circumcision", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1614.6, "gross_charge": 2484.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100482", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "54230", "type": "HCPCS" } ], "description": "Hc Inj Corpora Cavernosography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2616.25, "gross_charge": 4025.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100483", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55000", "type": "HCPCS" } ], "description": "Hc Punc Asp Hydrocele Tunica Vag", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1120.6, "gross_charge": 1724.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100483_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55000", "type": "HCPCS" } ], "description": "Hc Punc Asp Hydrocele Tunica Vag", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2241.2, "gross_charge": 3448.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100484", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55700", "type": "HCPCS" } ], "description": "Hc Biopsy Prostate Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1394.9, "gross_charge": 2146.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100485", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55875", "type": "HCPCS" } ], "description": "Hc Placement Needle Transperineal Prostate", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3623.75, "gross_charge": 5575.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100487", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "57155", "type": "HCPCS" } ], "description": "Hc Insertion Uterine Tandem Ovoid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3250.0, "gross_charge": 5000.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100488", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "58100", "type": "HCPCS" } ], "description": "Hc Endometrial Sampling Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 664.3, "gross_charge": 1022.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100489", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "58340", "type": "HCPCS" } ], "description": "Hc Catheterization For Hysterosalpingogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 367.25, "gross_charge": 565.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100490", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "58345", "type": "HCPCS" } ], "description": "Hc Introduction Catheter Fallopian Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8027.5, "gross_charge": 12350.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100490_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "58345", "type": "HCPCS" } ], "description": "Hc Introduction Catheter Fallopian Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 16055.0, "gross_charge": 24700.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100491", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "58350", "type": "HCPCS" } ], "description": "Hc Reopen Fallopian Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15319.85, "gross_charge": 23569.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100491_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "58350", "type": "HCPCS" } ], "description": "Hc Reopen Fallopian Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 30639.7, "gross_charge": 47138.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100492", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49407", "type": "HCPCS" } ], "description": "Hc Img Guide Fluid Coll Drng By Cath Transvag Or Rec Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8944.0, "gross_charge": 13760.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100493", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "58999", "type": "HCPCS" } ], "description": "Hc Unlisted Fem Genital Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1236.95, "gross_charge": 1903.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100494", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "59000", "type": "HCPCS" } ], "description": "Hc Amniocentesis Diagnostic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1672.45, "gross_charge": 2573.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100495", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "59001", "type": "HCPCS" } ], "description": "Hc Amniocentesis Therapeutic W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1755.65, "gross_charge": 2701.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100496", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "59012", "type": "HCPCS" } ], "description": "Hc Cordocentisis Intrauterine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1127.1, "gross_charge": 1734.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100497", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "59020", "type": "HCPCS" } ], "description": "Hc Fetal Contraction Stress Test", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 664.3, "gross_charge": 1022.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100498", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "59320", "type": "HCPCS" } ], "description": "Hc Cerclage Cervix During Pregnancy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4049.5, "gross_charge": 6230.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100499", "type": "CDM" }, { "code": "360", "type": "RC" }, { "code": "59350", "type": "HCPCS" } ], "description": "Hc Hysterorrhaphy Ruptured Uterus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5034.25, "gross_charge": 7745.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100500", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "60100", "type": "HCPCS" } ], "description": "Hc Biopsy Thyroid Percutaneous Core Needle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1147.25, "gross_charge": 1765.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100501", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "60300", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Thyroid Cyst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1147.25, "gross_charge": 1765.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100502", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "60699", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Endocrine System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5419.05, "gross_charge": 8337.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100503", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61050", "type": "HCPCS" } ], "description": "Hc Cervical Puncture", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 98.8, "gross_charge": 152.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100504", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61055", "type": "HCPCS" } ], "description": "Hc Cervical Puncture W Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100505", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61070", "type": "HCPCS" } ], "description": "Hc Puncture Shunt Tube For Asp Or Inj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1760.2, "gross_charge": 2708.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100506", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61623", "type": "HCPCS" } ], "description": "Hc Endovasc Temp Balloon Arterial Occlus Head Or Neck", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16052.4, "gross_charge": 24696.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100507", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61624", "type": "HCPCS" } ], "description": "Hc Transcath Permanent Occlus Or Embol Cns", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19542.25, "gross_charge": 30065.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100508", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61626", "type": "HCPCS" } ], "description": "Hc Transcath Permanent Occlus Or Embol Non Cns", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22790.3, "gross_charge": 35062.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100509", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61630", "type": "HCPCS" } ], "description": "Hc Balloon Angioplasty Intracranial Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8027.5, "gross_charge": 12350.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100510", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61635", "type": "HCPCS" } ], "description": "Hc Stent Intracranial Transcath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16055.0, "gross_charge": 24700.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100511", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61640", "type": "HCPCS" } ], "description": "Hc Balloon Dilat Intracranial Vasospasm Init Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18821.4, "gross_charge": 28956.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100512", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61642", "type": "HCPCS" } ], "description": "Hc Blln Dilat Intracran Vasospasm Addl Ves Diff Vas Territory", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12243.4, "gross_charge": 18836.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100515", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62264", "type": "HCPCS" } ], "description": "Hc Perc Lysis Of Adhesions Mult Sessns 1 Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10654.8, "gross_charge": 16392.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100516", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62267", "type": "HCPCS" } ], "description": "Hc Percutaneous Aspiration Intervertebral Disc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9781.85, "gross_charge": 15049.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100517", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62268", "type": "HCPCS" } ], "description": "Hc Percutaneous Aspiration Spinal Cord Cyst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14833.0, "gross_charge": 22820.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100518", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62270", "type": "HCPCS" } ], "description": "Hc Spinal Puncture Lumbar Diagnostic Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1263.6, "gross_charge": 1944.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100519", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62272", "type": "HCPCS" } ], "description": "Hc Spinal Puncture Lumbar Therapeutic Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3075.8, "gross_charge": 4732.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100520", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62273", "type": "HCPCS" } ], "description": "Hc Injection Epidural Of Blood Clot Or Patch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3841.5, "gross_charge": 5910.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100523", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62284", "type": "HCPCS" } ], "description": "Hc Injection Myelogram Spinal Not C1 C2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1051.05, "gross_charge": 1617.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100524", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62287", "type": "HCPCS" } ], "description": "Hc Perc Decompression 1 Or More Levels Lumbar", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4478.5, "gross_charge": 6890.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100525", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62290", "type": "HCPCS" } ], "description": "Hc Injection For Discogram Lumbar", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3405.35, "gross_charge": 5239.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100526", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62291", "type": "HCPCS" } ], "description": "Hc Injection For Discogram Cervical Or Thoracic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3405.35, "gross_charge": 5239.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100531", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62355", "type": "HCPCS" } ], "description": "Hc Remove Spinal Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1965.6, "gross_charge": 3024.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100532", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62362", "type": "HCPCS" } ], "description": "Hc Implant Or Replace Programmable Pump", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 51474.8, "gross_charge": 79192.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100533", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62365", "type": "HCPCS" } ], "description": "Hc Removal Subq Reservoir Or Pump", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11948.95, "gross_charge": 18383.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100534", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62368", "type": "HCPCS" } ], "description": "Hc Elec Anlys Progrmble Pump W Reprgrm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1824.55, "gross_charge": 2807.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100535", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62369", "type": "HCPCS" } ], "description": "Hc Elec Anlys Progrmble Pump W Reprgrm And Refill", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1617.85, "gross_charge": 2489.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100536", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62370", "type": "HCPCS" } ], "description": "Hc Elec Anlys Prgrmble Pump W Rprgrm And Fill Phys Asst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1617.85, "gross_charge": 2489.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100537", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "63650", "type": "HCPCS" } ], "description": "Hc Perc Implant Neurostim Electrode Array", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16120.0, "gross_charge": 24800.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100538", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "63661", "type": "HCPCS" } ], "description": "Hc Remove Neuro Electrode Perc Array", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10654.8, "gross_charge": 16392.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100539", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "63663", "type": "HCPCS" } ], "description": "Hc Revise Neuroelectrode Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16342.3, "gross_charge": 25142.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100540", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "63685", "type": "HCPCS" } ], "description": "Hc Ins Or Repl Spinal Neurostim Pulse Gen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7350.2, "gross_charge": 11308.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100541", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "63688", "type": "HCPCS" } ], "description": "Hc Revise Or Remove Neurostimulator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2330.25, "gross_charge": 3585.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100542", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64400", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trigeminal Nerve Each Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 730.6, "gross_charge": 1124.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100542_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64400", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trigeminal Nerve Each Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1461.2, "gross_charge": 2248.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100544", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64405", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Greater Occipital Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1095.9, "gross_charge": 1686.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100544_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64405", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Greater Occipital Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2191.8, "gross_charge": 3372.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100545", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64415", "type": "HCPCS" } ], "description": "Hc Injection Anes Brachial Plexus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3252.6, "gross_charge": 5004.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100545_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64415", "type": "HCPCS" } ], "description": "Hc Injection Anes Brachial Plexus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6505.2, "gross_charge": 10008.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100546", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64418", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Suprascapular Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3846.7, "gross_charge": 5918.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100546_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64418", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Suprascapular Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7693.4, "gross_charge": 11836.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100547", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64420", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Intercostal Nerve Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2278.9, "gross_charge": 3506.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100548", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64421", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Intercostal Nerves Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3888.95, "gross_charge": 5983.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100549", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64425", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Ilioinguinal Or Ileohypergastric Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2278.9, "gross_charge": 3506.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100549_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64425", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Ilioinguinal Or Ileohypergastric Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4557.8, "gross_charge": 7012.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100550", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64430", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Pudendal Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4457.7, "gross_charge": 6858.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100550_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64430", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Pudendal Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8915.4, "gross_charge": 13716.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100551", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64445", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Sciatic Nerve Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3846.7, "gross_charge": 5918.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100551_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64445", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Sciatic Nerve Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7693.4, "gross_charge": 11836.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100553", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64447", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Femoral Nerve Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1673.1, "gross_charge": 2574.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100553_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64447", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Femoral Nerve Single", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3346.2, "gross_charge": 5148.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100555", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64450", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Other Peripheral Nerve Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1285.05, "gross_charge": 1977.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100555_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64450", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Other Peripheral Nerve Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2570.1, "gross_charge": 3954.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100556", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64455", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Plantar Common Digital Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1095.9, "gross_charge": 1686.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100556_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64455", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Plantar Common Digital Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2191.8, "gross_charge": 3372.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100557", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64479", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trnsfrmnl Epi Cerv/Thor W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2177.5, "gross_charge": 3350.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100557_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64479", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trnsfrmnl Epi Cerv/Thor W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4355.0, "gross_charge": 6700.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100558", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64480", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trnsfrmnl Epi Cerv/Thor W Img Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1260.35, "gross_charge": 1939.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100559", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64483", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trnsfrmnl Epi Lumb/Sacr W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2177.5, "gross_charge": 3350.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100559_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64483", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trnsfrmnl Epi Lumb/Sacr W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4355.0, "gross_charge": 6700.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100560", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64484", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Trnsfrmnl Epi Lumb/Sacr W Img Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1260.35, "gross_charge": 1939.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100561", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64490", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Crv Or Thrc W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2930.2, "gross_charge": 4508.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100561_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64490", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Crv Or Thrc W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 5860.4, "gross_charge": 9016.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100562", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64491", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Crv Or Thrc W Img 2Nd Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1729.65, "gross_charge": 2661.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100563", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64492", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Crv Or Thrc W Img 3Rd Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1729.65, "gross_charge": 2661.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100564", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64493", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Lum Or Sacr W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3700.45, "gross_charge": 5693.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100564_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64493", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Lum Or Sacr W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7400.9, "gross_charge": 11386.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100565", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64494", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Lum Or Sacr W Img 2Nd Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1369.55, "gross_charge": 2107.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100566", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64495", "type": "HCPCS" } ], "description": "Hc Injection Anes Facet Joint Lum Or Sacr W Img 3Rd Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1369.55, "gross_charge": 2107.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100567", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64510", "type": "HCPCS" } ], "description": "Hc Injection Anes Stellate Ganglion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4830.8, "gross_charge": 7432.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100567_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64510", "type": "HCPCS" } ], "description": "Hc Injection Anes Stellate Ganglion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 9661.6, "gross_charge": 14864.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100568", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64517", "type": "HCPCS" } ], "description": "Hc Injection Anes Superior Hypogastric Plexus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7134.4, "gross_charge": 10976.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100569", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64520", "type": "HCPCS" } ], "description": "Hc Injection Anes Lumbar Sympathetic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4850.95, "gross_charge": 7463.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100569_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64520", "type": "HCPCS" } ], "description": "Hc Injection Anes Lumbar Sympathetic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 9701.9, "gross_charge": 14926.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100570", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64530", "type": "HCPCS" } ], "description": "Hc Injection Anes Celiac Plexus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5219.5, "gross_charge": 8030.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100575", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64600", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Trigeminal Nerve Supraorb Or Infraorb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7305.35, "gross_charge": 11239.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100578", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64620", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Intercostal Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5128.5, "gross_charge": 7890.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100579", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64630", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Pudendal Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2048.15, "gross_charge": 3151.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100580", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64632", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Plantar Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3208.4, "gross_charge": 4936.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100580_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64632", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Plantar Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6416.8, "gross_charge": 9872.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100581", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64633", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Facet Joint Cerv Or Thrc W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5383.3, "gross_charge": 8282.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100581_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64633", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Facet Joint Cerv Or Thrc W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 10766.6, "gross_charge": 16564.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100582", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64634", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Facet Joint Cerv Or Thrc W Img Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2870.4, "gross_charge": 4416.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100583", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64635", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Facet Joint Lumb Or Sacr W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4115.15, "gross_charge": 6331.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100583_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64635", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Facet Joint Lumb Or Sacr W Img Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8230.3, "gross_charge": 12662.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100584", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64636", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Facet Joint Lumb Or Sacr W Img Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2889.25, "gross_charge": 4445.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100585", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64640", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Other Peripheral Nerve Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1965.6, "gross_charge": 3024.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100585_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64640", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Other Peripheral Nerve Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3931.2, "gross_charge": 6048.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100586", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64680", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Celiac Plexus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5203.9, "gross_charge": 8006.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100587", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64681", "type": "HCPCS" } ], "description": "Hc Dest Neurolytic Superior Hypogastric Plexus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5215.6, "gross_charge": 8024.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100590", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Nervous System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4115.15, "gross_charge": 6331.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100591", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "92974", "type": "HCPCS" } ], "description": "Hc Transcath Plcmnt Radiation Del Dev", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1452.1, "gross_charge": 2234.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100592", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "95970", "type": "HCPCS" } ], "description": "Hc Elect Analysis Neurostim Gen Wo Prog", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 413.4, "gross_charge": 636.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100593", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "95971", "type": "HCPCS" } ], "description": "Hc Elect Analysis Neurostim Gen Simple Spine W Prog", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 365.95, "gross_charge": 563.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100594", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "95972", "type": "HCPCS" } ], "description": "Hc Elect Analysis Neurostim Gen Brn Complex Spine W Prog", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1097.85, "gross_charge": 1689.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100598", "type": "CDM" }, { "code": "361", "type": "RC" } ], "description": "Hc Lac Repair Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 916.5, "gross_charge": 1410.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100599", "type": "CDM" }, { "code": "361", "type": "RC" } ], "description": "Hc Lac Repair Ea Addl 5Cm Or Less Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 237.25, "gross_charge": 365.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100600", "type": "CDM" }, { "code": "361", "type": "RC" } ], "description": "Hc Or Level 1 Ep 1St 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2747.55, "gross_charge": 4227.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100601", "type": "CDM" }, { "code": "361", "type": "RC" } ], "description": "Hc Or Level 1 Ep Addl 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 735.15, "gross_charge": 1131.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100604", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0075T", "type": "HCPCS" } ], "description": "Hc Transcath Stent Xtracran Cca Perc Initial Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32926.4, "gross_charge": 50656.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100605", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0076T", "type": "HCPCS" } ], "description": "Hc Transcath Stent Xtracran Cca Perc Addl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14820.0, "gross_charge": 22800.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100608", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0200T", "type": "HCPCS" } ], "description": "Hc Sacroplasty Inj Unilat W Balloon Or Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22739.6, "gross_charge": 34984.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100608_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0200T", "type": "HCPCS" } ], "description": "Hc Sacroplasty Inj Unilat W Balloon Or Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 45479.2, "gross_charge": 69968.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100609", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0201T", "type": "HCPCS" } ], "description": "Hc Sacroplasty Inj Bilat W Balloon Or Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24744.85, "gross_charge": 38069.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100613", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0237T", "type": "HCPCS" } ], "description": "Hc Translum Peripheral Atherectomy Brachiocephalic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15589.6, "gross_charge": 23984.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100614", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0238T", "type": "HCPCS" } ], "description": "Hc Translum Peripheral Atherectomy Iliac Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19892.6, "gross_charge": 30604.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100619", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "G0260", "type": "HCPCS" } ], "description": "Hc Inj Sacroiliac Joint Anes/ Steroid W Or Wo Arthrogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3021.85, "gross_charge": 4649.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100619_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "G0260", "type": "HCPCS" } ], "description": "Hc Inj Sacroiliac Joint Anes/ Steroid W Or Wo Arthrogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6043.7, "gross_charge": 9298.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100620", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "G0269", "type": "HCPCS" } ], "description": "Hc Placement Occlusive Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 188.5, "gross_charge": 290.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100624", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11200", "type": "HCPCS" } ], "description": "Hc Skin Tag Removal 1-15 Lesions", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 768.3, "gross_charge": 1182.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100627", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11402", "type": "HCPCS" } ], "description": "Hc Exc Bng Lsn Mrgs 1.1-2.0 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1391.0, "gross_charge": 2140.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100660", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27599", "type": "HCPCS" } ], "description": "Hc Unlist Procd Femur Knee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3505.45, "gross_charge": 5393.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100660_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27599", "type": "HCPCS" } ], "description": "Hc Unlist Procd Femur Knee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7010.9, "gross_charge": 10786.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100713", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36555", "type": "HCPCS" } ], "description": "Hc Insert Nontunnel Cv Cath Younger Than 5 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2149.55, "gross_charge": 3307.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100716", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62322", "type": "HCPCS" } ], "description": "Hc Pain Procedure Lumbar Or Sacral Wo Fluoro 1St 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4290.65, "gross_charge": 6601.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100717", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10030", "type": "HCPCS" } ], "description": "Hc Img Guide Fluid Coll Drng By Cath Soft Tissue Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1060.15, "gross_charge": 1631.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100718", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19081", "type": "HCPCS" } ], "description": "Hc Bx Breast W Device Stereotactic 1St Les5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3849.95, "gross_charge": 5923.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100719", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19082", "type": "HCPCS" } ], "description": "Hc Bx Breast W Device Stereotactic Addl Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1029.6, "gross_charge": 1584.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100720", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19083", "type": "HCPCS" } ], "description": "Hc Bx Breast W Device Us Guidance 1St Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3849.95, "gross_charge": 5923.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100721", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19084", "type": "HCPCS" } ], "description": "Hc Bx Breast W Device Us Guidance Addl Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1029.6, "gross_charge": 1584.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100722", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19085", "type": "HCPCS" } ], "description": "Hc Bx Breast W Device Mr Guidance 1St Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3515.2, "gross_charge": 5408.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100723", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19086", "type": "HCPCS" } ], "description": "Hc Bx Breast W Device Mr Guidance Addl Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1029.6, "gross_charge": 1584.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100724", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19281", "type": "HCPCS" } ], "description": "Hc Plc Breast Lcl Device W Mammo Guid 1St Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2005.9, "gross_charge": 3086.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100725", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19282", "type": "HCPCS" } ], "description": "Hc Plc Breast Lcl Device W Mammo Guid Addl Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 512.2, "gross_charge": 788.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100726", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19283", "type": "HCPCS" } ], "description": "Hc Plc Breast Lcl Device Stereotactic 1St Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 871.0, "gross_charge": 1340.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100727", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19284", "type": "HCPCS" } ], "description": "Hc Plc Breast Lcl Device Stereotactic Addl Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 521.3, "gross_charge": 802.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100728", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19285", "type": "HCPCS" } ], "description": "Hc Plc Breast Lcl Device Us Guidance 1St Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 871.0, "gross_charge": 1340.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100729", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "19286", "type": "HCPCS" } ], "description": "Hc Plc Breast Lcl Device Us Guidance Addl Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 512.2, "gross_charge": 788.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100733", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33366", "type": "HCPCS" } ], "description": "Hc Trcath Replace Aortic Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100735", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34842", "type": "HCPCS" } ], "description": "Hc Endovasc Visc Aorta 2 Graft", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11165.7, "gross_charge": 17178.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100742", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37217", "type": "HCPCS" } ], "description": "Hc Stent Placemt Retro Carotid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12995.45, "gross_charge": 19993.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100742_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37217", "type": "HCPCS" } ], "description": "Hc Stent Placemt Retro Carotid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 25990.9, "gross_charge": 39986.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100743", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37236", "type": "HCPCS" } ], "description": "Hc Open Or Perq Place Stent 1St Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11374.35, "gross_charge": 17499.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100743_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37236", "type": "HCPCS" } ], "description": "Hc Open Or Perq Place Stent 1St Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 22748.7, "gross_charge": 34998.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100744", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37237", "type": "HCPCS" } ], "description": "Hc Open Or Perq Place Stent Ea Add Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5686.2, "gross_charge": 8748.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100745", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37238", "type": "HCPCS" } ], "description": "Hc Open Or Perq Place Stent 1St Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11374.35, "gross_charge": 17499.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100745_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37238", "type": "HCPCS" } ], "description": "Hc Open Or Perq Place Stent 1St Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 22748.7, "gross_charge": 34998.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100746", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37239", "type": "HCPCS" } ], "description": "Hc Open Or Perq Place Stent Ea Add Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5686.2, "gross_charge": 8748.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100747", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37241", "type": "HCPCS" } ], "description": "Hc Vasc Embolize Occlude Venous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19947.2, "gross_charge": 30688.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100748", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37242", "type": "HCPCS" } ], "description": "Hc Vasc Embolize Occlude Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19947.2, "gross_charge": 30688.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100749", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37243", "type": "HCPCS" } ], "description": "Hc Vasc Embolize Occlude Organ Tumor Infarct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19947.2, "gross_charge": 30688.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100750", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37244", "type": "HCPCS" } ], "description": "Hc Vasc Embolize Occlude Bleed", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19947.2, "gross_charge": 30688.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100753", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33270", "type": "HCPCS" } ], "description": "Hc Insert Subq Defib W Electrode", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15613.0, "gross_charge": 24020.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100754", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33271", "type": "HCPCS" } ], "description": "Hc Insert Subq Defib Electrode", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14290.9, "gross_charge": 21986.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100758", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33272", "type": "HCPCS" } ], "description": "Hc Removal Subq Defib Electrode", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13554.45, "gross_charge": 20853.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100759", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33273", "type": "HCPCS" } ], "description": "Hc Repos Subq Defib Electrode And Gen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14060.8, "gross_charge": 21632.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100760", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Hemic Or Lymphatic System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 521.3, "gross_charge": 802.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100761", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11442", "type": "HCPCS" } ], "description": "Hc Excise Benign Lesion Face 1.1-2Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3279.9, "gross_charge": 5046.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100762", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37766", "type": "HCPCS" } ], "description": "Hc Stab Phlb Veins 1 Extr > 20 Incis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9250.8, "gross_charge": 14232.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100762_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37766", "type": "HCPCS" } ], "description": "Hc Stab Phlb Veins 1 Extr > 20 Incis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 18501.6, "gross_charge": 28464.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100763", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31579", "type": "HCPCS" } ], "description": "Hc St Laryngoscopy With Stroboscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1281.8, "gross_charge": 1972.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100764", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20604", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Small W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2299.05, "gross_charge": 3537.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100764_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20604", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Small W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4598.1, "gross_charge": 7074.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100765", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20606", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Intermediate W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2855.45, "gross_charge": 4393.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100765_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20606", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Intermediate W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 5710.9, "gross_charge": 8786.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100766", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20611", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Large W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3133.65, "gross_charge": 4821.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100766_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20611", "type": "HCPCS" } ], "description": "Hc Asp Or Inj Joint Large W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6267.3, "gross_charge": 9642.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100771", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37218", "type": "HCPCS" } ], "description": "Hc Transcath Stent Intrathoracic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12995.45, "gross_charge": 19993.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100771_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37218", "type": "HCPCS" } ], "description": "Hc Transcath Stent Intrathoracic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 25990.9, "gross_charge": 39986.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100772", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62302", "type": "HCPCS" } ], "description": "Hc Inj Myelogram Cervical W Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2932.8, "gross_charge": 4512.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100773", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62303", "type": "HCPCS" } ], "description": "Hc Inj Myelogram Thoracic W Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3693.95, "gross_charge": 5683.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100774", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62304", "type": "HCPCS" } ], "description": "Hc Inj Myelogram Ls W Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3693.95, "gross_charge": 5683.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100775", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62305", "type": "HCPCS" } ], "description": "Hc Inj Myelogram 2 Or More Regions W Imaging", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4433.0, "gross_charge": 6820.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100776", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20983", "type": "HCPCS" } ], "description": "Hc Cryoablation Bone Tumor W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7861.75, "gross_charge": 12095.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100776_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20983", "type": "HCPCS" } ], "description": "Hc Cryoablation Bone Tumor W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 15723.5, "gross_charge": 24190.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100777", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47383", "type": "HCPCS" } ], "description": "Hc Cryoablation Liver Tumor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7056.4, "gross_charge": 10856.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100778", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32994", "type": "HCPCS" } ], "description": "Hc Cryoablation Pulm Tumor Unilat W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5980.0, "gross_charge": 9200.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100778_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32994", "type": "HCPCS" } ], "description": "Hc Cryoablation Pulm Tumor Unilat W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 11960.0, "gross_charge": 18400.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100779", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "51102", "type": "HCPCS" } ], "description": "Hc Aspiration Bladder W Ins Suprapubic Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3710.2, "gross_charge": 5708.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100780", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32553", "type": "HCPCS" } ], "description": "Hc Placement Fiducial Marker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1342.25, "gross_charge": 2065.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100781", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "57156", "type": "HCPCS" } ], "description": "Hc Insertion Vaginal Radiation Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1273.35, "gross_charge": 1959.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100784", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27279", "type": "HCPCS" } ], "description": "Hc Athrodesis Sacroiliac Joint W Img Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 49480.6, "gross_charge": 76124.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100784_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27279", "type": "HCPCS" } ], "description": "Hc Athrodesis Sacroiliac Joint W Img Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 98961.2, "gross_charge": 152248.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100785", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37609", "type": "HCPCS" } ], "description": "Hc Ligation/Biopsy Temporal Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2830.1, "gross_charge": 4354.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100785_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37609", "type": "HCPCS" } ], "description": "Hc Ligation/Biopsy Temporal Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 5660.2, "gross_charge": 8708.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100788", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47531", "type": "HCPCS" } ], "description": "Hc Injection For Dx Cholangiogram W Img Existing Access", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6555.9, "gross_charge": 10086.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100789", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47532", "type": "HCPCS" } ], "description": "Hc Injection For Dx Cholangiogram W Img New Access", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9456.2, "gross_charge": 14548.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100790", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47533", "type": "HCPCS" } ], "description": "Hc Place Biliary Drain Catheter W Img External", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15484.3, "gross_charge": 23822.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100791", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47534", "type": "HCPCS" } ], "description": "Hc Place Biliary Drain Catheter W Img Internal-External", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16258.45, "gross_charge": 25013.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100792", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47535", "type": "HCPCS" } ], "description": "Hc Convert Biliary Drain To Internal-External W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11313.9, "gross_charge": 17406.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100793", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47536", "type": "HCPCS" } ], "description": "Hc Exchange Biliary Drain Catheter W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9427.6, "gross_charge": 14504.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100794", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47537", "type": "HCPCS" } ], "description": "Hc Remove Biliary Drain Catheter W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1344.2, "gross_charge": 2068.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100795", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47538", "type": "HCPCS" } ], "description": "Hc Place Stent Bile Duct W Img Via Existing Access Each", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18063.5, "gross_charge": 27790.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100796", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47539", "type": "HCPCS" } ], "description": "Hc Place Stent Bile Duct W Img Via New Acc Wo Separate Bdc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20725.25, "gross_charge": 31885.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100797", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47540", "type": "HCPCS" } ], "description": "Hc Place Stent Bile Duct W Img Via New Acc W Separate Bdc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21676.2, "gross_charge": 33348.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100798", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47541", "type": "HCPCS" } ], "description": "Hc Place Access Thru Biliary Tree/ Small Int W Img Via New Acc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23185.5, "gross_charge": 35670.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100799", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47542", "type": "HCPCS" } ], "description": "Hc Balloon Dilation Biliary Duct Or Ampulla W Img Each Duct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9031.75, "gross_charge": 13895.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100800", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47543", "type": "HCPCS" } ], "description": "Hc Endoluminal Bx Biliary Tree W Img Single Or Mult Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7352.8, "gross_charge": 11312.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100801", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47544", "type": "HCPCS" } ], "description": "Hc Remove Calculi Or Debris From Biliary Duct Or Gallbladder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7352.8, "gross_charge": 11312.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100802", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50430", "type": "HCPCS" } ], "description": "Hc Inj For Dx Nephrostogram Or Ureterogram W Img Via New Acc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4364.1, "gross_charge": 6714.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100802_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50430", "type": "HCPCS" } ], "description": "Hc Inj For Dx Nephrostogram Or Ureterogram W Img Via New Acc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8728.2, "gross_charge": 13428.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100803", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50431", "type": "HCPCS" } ], "description": "Hc Inj For Dx Nephrostogram Or Ureterogram W Img Via Exist Acc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4364.1, "gross_charge": 6714.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100803_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50431", "type": "HCPCS" } ], "description": "Hc Inj For Dx Nephrostogram Or Ureterogram W Img Via Exist Acc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8728.2, "gross_charge": 13428.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100804", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50432", "type": "HCPCS" } ], "description": "Hc Place Nephrostomy Catheter W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7608.9, "gross_charge": 11706.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100804_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50432", "type": "HCPCS" } ], "description": "Hc Place Nephrostomy Catheter W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 15217.8, "gross_charge": 23412.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100805", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50433", "type": "HCPCS" } ], "description": "Hc Place Nephroureteral Catheter W Img Via New Access", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10193.95, "gross_charge": 15683.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100805_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50433", "type": "HCPCS" } ], "description": "Hc Place Nephroureteral Catheter W Img Via New Access", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 20387.9, "gross_charge": 31366.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100806", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50434", "type": "HCPCS" } ], "description": "Hc Convert Nephrostomy Cath To Nephroureteral Cath W Img Exist Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6340.75, "gross_charge": 9755.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100806_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50434", "type": "HCPCS" } ], "description": "Hc Convert Nephrostomy Cath To Nephroureteral Cath W Img Exist Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 12681.5, "gross_charge": 19510.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100807", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50435", "type": "HCPCS" } ], "description": "Hc Exchange Nephrostomy Cath W Img Via Existing Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6340.75, "gross_charge": 9755.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100807_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50435", "type": "HCPCS" } ], "description": "Hc Exchange Nephrostomy Cath W Img Via Existing Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 12681.5, "gross_charge": 19510.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100808", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50606", "type": "HCPCS" } ], "description": "Hc Endoluminal Biopsy Ureter Or Renal Pelvis W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2290.6, "gross_charge": 3524.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100809", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50693", "type": "HCPCS" } ], "description": "Hc Place Ureteral Stent W Img Via Existing Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10193.95, "gross_charge": 15683.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100809_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50693", "type": "HCPCS" } ], "description": "Hc Place Ureteral Stent W Img Via Existing Tract", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 20387.9, "gross_charge": 31366.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100810", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50694", "type": "HCPCS" } ], "description": "Hc Place Ureteral Stent W Img Via New Access Wo Separate Neph Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10499.45, "gross_charge": 16153.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100810_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50694", "type": "HCPCS" } ], "description": "Hc Place Ureteral Stent W Img Via New Access Wo Separate Neph Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 20998.9, "gross_charge": 32306.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100811", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50695", "type": "HCPCS" } ], "description": "Hc Place Ureteral Stent W Img Via New Access W Separate Neph Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10805.6, "gross_charge": 16624.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100811_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50695", "type": "HCPCS" } ], "description": "Hc Place Ureteral Stent W Img Via New Access W Separate Neph Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 21611.2, "gross_charge": 33248.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100812", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50705", "type": "HCPCS" } ], "description": "Hc Ureteral Embolization Or Occlusion W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2181.4, "gross_charge": 3356.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100813", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50706", "type": "HCPCS" } ], "description": "Hc Balloon Dilation Or Ureteral Stricture W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2290.6, "gross_charge": 3524.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100814", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49185", "type": "HCPCS" } ], "description": "Hc Sclerotherapy For Fluid Collection W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6272.5, "gross_charge": 9650.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100815", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61645", "type": "HCPCS" } ], "description": "Hc Perc Art Trans Mech Thrombectomy Or Infus For Thrombolysis Intracranial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24677.9, "gross_charge": 37966.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100815_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61645", "type": "HCPCS" } ], "description": "Hc Perc Art Trans Mech Thrombectomy Or Infus For Thrombolysis Intracranial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 49355.8, "gross_charge": 75932.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100816", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64461", "type": "HCPCS" } ], "description": "Hc Paravertebral Block Thoracic W Img Single Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4290.65, "gross_charge": 6601.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100816_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64461", "type": "HCPCS" } ], "description": "Hc Paravertebral Block Thoracic W Img Single Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8581.3, "gross_charge": 13202.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100817", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64462", "type": "HCPCS" } ], "description": "Hc Paravertebral Block Thoracic W Img Addl Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2145.0, "gross_charge": 3300.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100819", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37252", "type": "HCPCS" } ], "description": "Hc Ivus Non-Coronary Initial Vessel W Img Initial Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3472.95, "gross_charge": 5343.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100820", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37253", "type": "HCPCS" } ], "description": "Hc Ivus Non-Coronary Initial Vessel W Img Ea Addl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1335.75, "gross_charge": 2055.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100821", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61650", "type": "HCPCS" } ], "description": "Hc Endo Intracranial Prolong Adm Of Pharm Agent Nonthrom W Img Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20803.9, "gross_charge": 32006.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100822", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61651", "type": "HCPCS" } ], "description": "Hc Endo Intracranial Prolong Adm Of Pharm Agent Nonthrom W Img Ea Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6022.9, "gross_charge": 9266.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100823", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31652", "type": "HCPCS" } ], "description": "Hc Bronchoscopy Endobronchial Us 1-2 Nodes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6262.1, "gross_charge": 9634.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100824", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31653", "type": "HCPCS" } ], "description": "Hc Bronchoscopy Endobronchial Us 3 Or More Nodes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6262.1, "gross_charge": 9634.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100825", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31654", "type": "HCPCS" } ], "description": "Hc Bronchoscopy W Ebus W Intvj Periph Lesions", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3376.75, "gross_charge": 5195.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100827", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64616", "type": "HCPCS" } ], "description": "Hc Chemodenervation Neck Muscle Dystonia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2481.7, "gross_charge": 3818.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100827_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64616", "type": "HCPCS" } ], "description": "Hc Chemodenervation Neck Muscle Dystonia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4963.4, "gross_charge": 7636.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100829", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49460", "type": "HCPCS" } ], "description": "Hc Obstructive Material Removal From Gi Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9395.75, "gross_charge": 14455.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100830", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49411", "type": "HCPCS" } ], "description": "Hc Plcmnt Fiducial Dev Rt Guid Abd Pelvis Retro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1342.25, "gross_charge": 2065.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100836", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36901", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Intro Needle/Cath W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3183.05, "gross_charge": 4897.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100837", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36902", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Intro Needle/Cath W Tba Peripheral W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10823.8, "gross_charge": 16652.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100838", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36903", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Intro Needle/Cath W Plcmt Of Stent Peripheral W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 23255.05, "gross_charge": 35777.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100839", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36904", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Perc Thrombectomy Or Thrombolysis Infu W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10026.25, "gross_charge": 15425.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100840", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36905", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Perc Thrombectomy Or Thrombolysis Infu W Tba Peripheral W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15987.4, "gross_charge": 24596.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100841", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36906", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Perc Thrombectomy Or Thrombolysis Infu W Plcmt Of Stent Peripheral W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 28418.0, "gross_charge": 43720.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100842", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36907", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Tba Central W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7641.4, "gross_charge": 11756.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100843", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36908", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Plcmt Of Stent Central Incld Angioplasty W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9782.5, "gross_charge": 15050.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100844", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36909", "type": "HCPCS" } ], "description": "Hc Dialysis Circuit Vasc Embolization Or Occlusion W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9782.5, "gross_charge": 15050.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100845", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37246", "type": "HCPCS" } ], "description": "Hc Transluminal Balloon Angioplasty W Img Artery Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10505.3, "gross_charge": 16162.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100845_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37246", "type": "HCPCS" } ], "description": "Hc Transluminal Balloon Angioplasty W Img Artery Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 21010.6, "gross_charge": 32324.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100846", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37247", "type": "HCPCS" } ], "description": "Hc Transluminal Balloon Angioplasty W Img Artery Each Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7930.0, "gross_charge": 12200.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100847", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37248", "type": "HCPCS" } ], "description": "Hc Transluminal Balloon Angioplasty W Img Vein Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10592.4, "gross_charge": 16296.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100847_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37248", "type": "HCPCS" } ], "description": "Hc Transluminal Balloon Angioplasty W Img Vein Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 21184.8, "gross_charge": 32592.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100848", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "37249", "type": "HCPCS" } ], "description": "Hc Transluminal Balloon Angioplasty W Img Vein Each Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7641.4, "gross_charge": 11756.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100849", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62320", "type": "HCPCS" } ], "description": "Hc Injection Dx Or Ther Epidur Or Subarach Cer Or Thor Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5069.35, "gross_charge": 7799.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100850", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62321", "type": "HCPCS" } ], "description": "Hc Injection Dx Or Ther Epidur Or Subarach Cer Or Thor W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5265.0, "gross_charge": 8100.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100851", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62322", "type": "HCPCS" } ], "description": "Hc Injection Dx Or Ther Epidur Or Subarach Lum Or Sacr Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4290.65, "gross_charge": 6601.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100852", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62323", "type": "HCPCS" } ], "description": "Hc Injection Dx Or Ther Epidur Or Subarach Lum Or Sacr W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4732.65, "gross_charge": 7281.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100856", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62327", "type": "HCPCS" } ], "description": "Hc Injection Incl Cath Plcmnt Lumbar Or Sacral W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8867.95, "gross_charge": 13643.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100873", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20615", "type": "HCPCS" } ], "description": "Hc Aspiration And Injection Bone Cyst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1166.75, "gross_charge": 1795.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100874", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61641", "type": "HCPCS" } ], "description": "Hc Blln Dilat Intracran Vasospasm Addl Ves Same Vas Territory", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12243.4, "gross_charge": 18836.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100875", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28825", "type": "HCPCS" } ], "description": "Hc Amputation Toe Interphalangeal Joint", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3013.4, "gross_charge": 4636.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100876", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "23405", "type": "HCPCS" } ], "description": "Hc Tenotomy Shoulder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8748.35, "gross_charge": 13459.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100877", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62252", "type": "HCPCS" } ], "description": "Hc Cfs Shunt Reprogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 578.5, "gross_charge": 890.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100880", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55876", "type": "HCPCS" } ], "description": "Hc Plcmnt Interstial Dev Prostate Sngl Or Mult For Rad Therapy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10513.1, "gross_charge": 16174.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100882", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "36410", "type": "HCPCS" } ], "description": "Hc Venipuncture Or Midline Cath By Phys Or Qhcp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 994.5, "gross_charge": 1530.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100884", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27040", "type": "HCPCS" } ], "description": "Hc Biopsy Pelvis Or Hip Soft Tissue Superficial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3088.8, "gross_charge": 4752.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100885", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28010", "type": "HCPCS" } ], "description": "Hc Tenotomy Percutaneous Single Toe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2034.5, "gross_charge": 3130.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100886", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38222", "type": "HCPCS" } ], "description": "Hc Bone Marrow Diagnostic Biopsy(Ies) And Aspiration(S)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3380.65, "gross_charge": 5201.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100892", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34701", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Infrnl Aorta By Aorto-Aortic Endgrft Not Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 28197.0, "gross_charge": 43380.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100893", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34702", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Infrnl Aorta By Aorto-Aortic Endgrft Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 28197.0, "gross_charge": 43380.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100894", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34703", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Infrnl Aort/Ilc Art By Aorto-Uni-Ilc Endgrft Not Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 28796.95, "gross_charge": 44303.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100895", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34704", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Infrnl Aort/Ilc Art By Aorto-Uni-Ilc Endgrft Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 28796.95, "gross_charge": 44303.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100896", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34705", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Infrnl Aort/Ilc Art By Aorto-Bi-Ilc Endgrft Not Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29823.3, "gross_charge": 45882.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100897", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34706", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Infrnl Aort/Ilc Art By Aorto-Bi-Ilc Endgrft Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29823.3, "gross_charge": 45882.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100898", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34707", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Iliac Art By Ilio-Iliac Endgrft Uni Not Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32962.8, "gross_charge": 50712.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100899", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34708", "type": "HCPCS" } ], "description": "Hc Endvsc Rep Iliac Art By Ilio-Iliac Endgrft Uni Rupt W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32962.8, "gross_charge": 50712.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100900", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34709", "type": "HCPCS" } ], "description": "Hc Plcmnt Ext Prosthesis For Endovasc Rep Per Vessel W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10638.55, "gross_charge": 16367.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100901", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34710", "type": "HCPCS" } ], "description": "Hc Delayed Plcmnt Ext Prosthesis For Endovasc Rep Init Vessel W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12146.55, "gross_charge": 18687.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100902", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34711", "type": "HCPCS" } ], "description": "Hc Delayed Plcmnt Ext Prosthesis For Endovasc Rep Ea Addl Vessel W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10650.25, "gross_charge": 16385.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100903", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34712", "type": "HCPCS" } ], "description": "Hc Transcatheter Delivery Fixation Devices To Endograft W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10201.75, "gross_charge": 15695.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100904", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34713", "type": "HCPCS" } ], "description": "Hc Perc Access & Closure Fem Art For Endgrft Del Uni W Img Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11328.85, "gross_charge": 17429.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100905", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36465", "type": "HCPCS" } ], "description": "Hc Inj Foam Sclerosant W Ultrasound Compression Extremity Single Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1942.2, "gross_charge": 2988.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100906", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36466", "type": "HCPCS" } ], "description": "Hc Inj Foam Sclerosant W Ultrasound Compression Extremity Multiple Veins", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2913.3, "gross_charge": 4482.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100907", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36482", "type": "HCPCS" } ], "description": "Hc Endoven Ablat Incompetent Ext Vein W Img Initial Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3753.1, "gross_charge": 5774.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100908", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36483", "type": "HCPCS" } ], "description": "Hc Endoven Ablat Incompetent Ext Vein W Img Addl Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2444.65, "gross_charge": 3761.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100909", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27041", "type": "HCPCS" } ], "description": "Hc Biopsy Pelvis Or Hip Soft Tissue Deep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3140.8, "gross_charge": 4832.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100910", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33968", "type": "HCPCS" } ], "description": "Hc Removal Of Iapb Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 631.15, "gross_charge": 971.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100911", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49425", "type": "HCPCS" } ], "description": "Hc Insert Peritoneal-Venous Shunt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4992.65, "gross_charge": 7681.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100912", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "47554", "type": "HCPCS" } ], "description": "Hc Biliary Endo Perc With Calculus Removal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6448.0, "gross_charge": 9920.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100913", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "20240", "type": "HCPCS" } ], "description": "Hc Biopsy Bone Open Superficial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3159.65, "gross_charge": 4861.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100914", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11982", "type": "HCPCS" } ], "description": "Hc Removal Nonbiodegrad Drug Delivery Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4769.7, "gross_charge": 7338.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100915", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49520", "type": "HCPCS" } ], "description": "Hc Repair Recurrent Inguinal Hernia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5669.95, "gross_charge": 8723.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100916", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10035", "type": "HCPCS" } ], "description": "Hc Place Soft Tissue Localization Device W Img 1St Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 871.0, "gross_charge": 1340.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100917", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10036", "type": "HCPCS" } ], "description": "Hc Place Soft Tissue Localization Device W Img Ea Addt Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 452.4, "gross_charge": 696.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100918", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32561", "type": "HCPCS" } ], "description": "Hc Instillation Via Chest Tube/Cath Fibrinolysis Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 854.75, "gross_charge": 1315.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100919", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28140", "type": "HCPCS" } ], "description": "Hc Metatarsectomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3122.6, "gross_charge": 4804.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100920", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10007", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy W Fluoro 1St Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3598.4, "gross_charge": 5536.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100921", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10008", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy W Fluoro Ea Addl Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1757.6, "gross_charge": 2704.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100922", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10009", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy W Ct 1St Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3598.4, "gross_charge": 5536.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100923", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10010", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy W Ct Ea Addl Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1757.6, "gross_charge": 2704.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100926", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11102", "type": "HCPCS" } ], "description": "Hc Tangential Biopsy Skin Single Les", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 439.4, "gross_charge": 676.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100927", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11103", "type": "HCPCS" } ], "description": "Hc Tangential Biopsy Skin Ea Sep/Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 234.65, "gross_charge": 361.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100928", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11104", "type": "HCPCS" } ], "description": "Hc Punch Biopsy Skin Single Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 474.5, "gross_charge": 730.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100929", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11105", "type": "HCPCS" } ], "description": "Hc Punch Biopsy Skin Ea Sep/Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 230.75, "gross_charge": 355.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100930", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11106", "type": "HCPCS" } ], "description": "Hc Incisional Biopsy Of Skin Single Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 863.2, "gross_charge": 1328.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100931", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11107", "type": "HCPCS" } ], "description": "Hc Incisional Biopsy Of Skin Each Additional", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 469.3, "gross_charge": 722.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100932", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27369", "type": "HCPCS" } ], "description": "Hc Injection For Contrast Knee Arthrography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1789.45, "gross_charge": 2753.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100933", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33274", "type": "HCPCS" } ], "description": "Hc Trcath Ins Or Repl Perm Leadless Pacer Right", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14487.2, "gross_charge": 22288.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100934", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33275", "type": "HCPCS" } ], "description": "Hc Trcath Remove Permanent Leadless Pacer Right W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14487.2, "gross_charge": 22288.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100935", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33285", "type": "HCPCS" } ], "description": "Hc Insert Subq Cardiac Rhythm Monitor Incl Programming", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12806.3, "gross_charge": 19702.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100936", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33286", "type": "HCPCS" } ], "description": "Hc Removal Of Subq Cardiac Rhythm Monitor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1554.15, "gross_charge": 2391.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100937", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33289", "type": "HCPCS" } ], "description": "Hc Trcath Implant Of Wireless Pulm Artery Pressure Sensor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15096.9, "gross_charge": 23226.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100940", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36573", "type": "HCPCS" } ], "description": "Hc Insert Picc, Wo Sq Port, With Imaging, > 5 Yo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3772.6, "gross_charge": 5804.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100941", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50436", "type": "HCPCS" } ], "description": "Hc Dilation Of Exst Tract W Guid W Tube Plcmt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12815.4, "gross_charge": 19716.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100942", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "50437", "type": "HCPCS" } ], "description": "Hc Dilation Of Exst Tract W Guid W Tube Plcmt Incl New Access", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13863.2, "gross_charge": 21328.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100948", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0505T", "type": "HCPCS" } ], "description": "Hc Endovenous Femoral-Popliteal Arterial Revasc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14530.75, "gross_charge": 22355.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100956", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0519T", "type": "HCPCS" } ], "description": "Hc Removal And Rplce Cardiac Stimulator Left", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15782.0, "gross_charge": 24280.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100957", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0520T", "type": "HCPCS" } ], "description": "Hc Removal And Rplce Cardiac Stimulator Left W New Electro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15782.0, "gross_charge": 24280.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100958", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10005", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy W Ultrasound 1St Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3331.9, "gross_charge": 5126.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100959", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10006", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy W Ultrasound Ea Addl Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1757.6, "gross_charge": 2704.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100960", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9752", "type": "HCPCS" } ], "description": "Hc Destrct Intraosseous Basivet Nerve First 2 Vert Incl Img Guid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8813.35, "gross_charge": 13559.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100961", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9753", "type": "HCPCS" } ], "description": "Hc Destrct Of Intraosseous Basivetnerve Ea Addl Incl Img Guid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 640.9, "gross_charge": 986.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100962", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10004", "type": "HCPCS" } ], "description": "Hc Fine Needle Asp Biopsy Wo Img Ea Addl Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 319.15, "gross_charge": 491.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100963", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "27299", "type": "HCPCS" } ], "description": "Hc Cementoplasty Of Acetabulum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3505.45, "gross_charge": 5393.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100964", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0523T", "type": "HCPCS" } ], "description": "Hc Intraprocedural Coronary Ffr Values For Stenosis Interven Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 309.4, "gross_charge": 476.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100966", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36585", "type": "HCPCS" } ], "description": "Hc Replace Pericath W Subq Port Same Venous Access", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9271.6, "gross_charge": 14264.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100967", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61880", "type": "HCPCS" } ], "description": "Hc Revision/Removal Intracranial Electrodes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2145.0, "gross_charge": 3300.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100968", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "61888", "type": "HCPCS" } ], "description": "Hc Revision/Removal Cranial Neurostim Pulse Gen Or Receiver", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19671.6, "gross_charge": 30264.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100970", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "57452", "type": "HCPCS" } ], "description": "Hc Colposcopy With Upper Adjacent Vagina", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 326.3, "gross_charge": 502.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100971", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "57455", "type": "HCPCS" } ], "description": "Hc Colposcopy With Biopsy(S)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 573.3, "gross_charge": 882.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100973", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "49442", "type": "HCPCS" } ], "description": "Hc Place Cecostomy Percutaneous W Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9452.95, "gross_charge": 14543.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100974", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33016", "type": "HCPCS" } ], "description": "Hc Pericardiocentesis W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8718.45, "gross_charge": 13413.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100975", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33017", "type": "HCPCS" } ], "description": "Hc Perc Pericardial Drainage W Fluoro Or Us", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10074.35, "gross_charge": 15499.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100976", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33019", "type": "HCPCS" } ], "description": "Hc Perc Pericardial Drainage W Ct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12012.0, "gross_charge": 18480.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100977", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62328", "type": "HCPCS" } ], "description": "Hc Spinal Puncture Diagnostic Lumbar W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3215.55, "gross_charge": 4947.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100978", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "62329", "type": "HCPCS" } ], "description": "Hc Spinal Puncture Therapeutic Drain Csf W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2809.95, "gross_charge": 4323.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100979", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64451", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Si Joint Nerves W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2955.55, "gross_charge": 4547.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100979_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64451", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Si Joint Nerves W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 5911.1, "gross_charge": 9094.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100980", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64454", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Genicular Nerve Branches W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2462.85, "gross_charge": 3789.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100980_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64454", "type": "HCPCS" } ], "description": "Hc Injection Anes/Steroid Genicular Nerve Branches W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4925.7, "gross_charge": 7578.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100981", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64625", "type": "HCPCS" } ], "description": "Hc Rf Ablation Nerves Inervating Si Joint W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4115.15, "gross_charge": 6331.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100981_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64625", "type": "HCPCS" } ], "description": "Hc Rf Ablation Nerves Inervating Si Joint W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8230.3, "gross_charge": 12662.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100984", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0567T", "type": "HCPCS" } ], "description": "Hc Perm Fallopian Tube Occ W Implnt Transcervical App W Trnsvg Us", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11478.35, "gross_charge": 17659.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100985", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0568T", "type": "HCPCS" } ], "description": "Hc Confirm Occ Of Fallopian Tubes Transcerv App Incl Transv And Pelvic Us", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 619.45, "gross_charge": 953.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100986", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0569T", "type": "HCPCS" } ], "description": "Hc Transcath Tricuspid Valve Repair Perct App Initial Prosthesis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100987", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0570T", "type": "HCPCS" } ], "description": "Hc Transcath Tricuspid Valve Repair Perct App Each Addtl Prosthesis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13943.15, "gross_charge": 21451.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100988", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0571T", "type": "HCPCS" } ], "description": "Hc Insert Or Replce Impnt Cardioverter Defib System W Substernal Elect Incl Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15613.0, "gross_charge": 24020.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100989", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0572T", "type": "HCPCS" } ], "description": "Hc Insertion Of Substernal Implantable Defib Electrode", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14290.9, "gross_charge": 21986.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100990", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0573T", "type": "HCPCS" } ], "description": "Hc Removal Of Substernal Implantable Defib Electrode", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14290.9, "gross_charge": 21986.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100991", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0574T", "type": "HCPCS" } ], "description": "Hc Reposition Of Prev Implanted Substernal Implantable Defib Pacing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14290.9, "gross_charge": 21986.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100992", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0580T", "type": "HCPCS" } ], "description": "Hc Removal Of Substernal Implantable Defib Pulse Generator Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14290.9, "gross_charge": 21986.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100993", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0581T", "type": "HCPCS" } ], "description": "Hc Cryoablation Breast Tumor Unilat W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3930.55, "gross_charge": 6047.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100993_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0581T", "type": "HCPCS" } ], "description": "Hc Cryoablation Breast Tumor Unilat W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7861.1, "gross_charge": 12094.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36100998", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34717", "type": "HCPCS" } ], "description": "Hc Endovasc Repair Of Iliac Artery At Time Of Aortoiliac Endograft Plcmt Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32962.8, "gross_charge": 50712.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100999", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34718", "type": "HCPCS" } ], "description": "Hc Endovasc Repair Of Iliac Artery Not Assoc W Aortoiliac Endograft Plcmt Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32962.8, "gross_charge": 50712.0, "setting": "both" } ] }, { "code_information": [ { "code": "36100999_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34718", "type": "HCPCS" } ], "description": "Hc Endovasc Repair Of Iliac Artery Not Assoc W Aortoiliac Endograft Plcmt Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 65925.6, "gross_charge": 101424.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36101000", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "20560", "type": "HCPCS" } ], "description": "Hc Needle Insertion Without Injection 1 Or 2 Muscles", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101001", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "20561", "type": "HCPCS" } ], "description": "Hc Needle Insertion Without Injection 3 Or More Muscles", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101004", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0587T", "type": "HCPCS" } ], "description": "Hc Perc Implnt/Rplc Integrated Sgl Device Neurostim Syst Posterior Tibial Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1200.55, "gross_charge": 1847.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101005", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0588T", "type": "HCPCS" } ], "description": "Hc Revise Or Rmv Integrated Sgl Device Neurostim Syst Posterior Tibial Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 776.1, "gross_charge": 1194.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101006", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0589T", "type": "HCPCS" } ], "description": "Hc Elect Anlys W/Smpl Prgrm Implant Integrated Neurostim Syst Post Tibial Nerve 1-3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 731.9, "gross_charge": 1126.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101007", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0590T", "type": "HCPCS" } ], "description": "Hc Elect Anlys/Cmplx Prgrm Implant Integrated Neurostim Syst Post Tibial Nerve 4+", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 731.9, "gross_charge": 1126.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101008", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64624", "type": "HCPCS" } ], "description": "Hc Destruct, Genicular Nerve Branches, Incl Image Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4115.15, "gross_charge": 6331.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101008_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64624", "type": "HCPCS" } ], "description": "Hc Destruct, Genicular Nerve Branches, Incl Image Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8230.3, "gross_charge": 12662.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36101011", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64644", "type": "HCPCS" } ], "description": "Hc Chemodenervation One Extremity 5 Or More Muscles", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3733.6, "gross_charge": 5744.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101012", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64645", "type": "HCPCS" } ], "description": "Hc Chemodenervation Ea Addl Extremity 5 Or More Muscles", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2575.3, "gross_charge": 3962.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101013", "type": "CDM" }, { "code": "922", "type": "RC" }, { "code": "95874", "type": "HCPCS" } ], "description": "Hc Needle Emg For Chemodenervation Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1194.7, "gross_charge": 1838.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101014", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0275T", "type": "HCPCS" } ], "description": "Hc Percutaneous Laminotomy Laminectomy Lumbar", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12351.3, "gross_charge": 19002.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101015", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33501", "type": "HCPCS" } ], "description": "Hc Rpair Cor Arteriovenous/Cardiac Fistula Wo Bypass", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10746.45, "gross_charge": 16533.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101016", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "48999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Pancreas", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3772.6, "gross_charge": 5804.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101017", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55250", "type": "HCPCS" } ], "description": "Hc Vasectomy Without Anesthesia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9300.2, "gross_charge": 14308.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101018", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64721", "type": "HCPCS" } ], "description": "Hc Neuroplasty Carpal Tunnel Median Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4184.7, "gross_charge": 6438.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101019", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0600T", "type": "HCPCS" } ], "description": "Hc Irrevers Electroporation Ablat Per Organ Perc W Imag", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11321.05, "gross_charge": 17417.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101020", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9764", "type": "HCPCS" } ], "description": "Hc Revas Intravasc Lithotripsy Incl Angioplasty", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13735.15, "gross_charge": 21131.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101021", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9765", "type": "HCPCS" } ], "description": "Hc Revas Intravsc Lithotrip And Transluminal Stent Plcmt Incl Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16444.35, "gross_charge": 25299.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101022", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9766", "type": "HCPCS" } ], "description": "Hc Revas Intravasc Lithotrip And Atherectomy Incl Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16444.35, "gross_charge": 25299.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101023", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9767", "type": "HCPCS" } ], "description": "Hc Revas Intravasc Lithotrip Translum Stent And Atherect Incl Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18271.5, "gross_charge": 28110.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101024", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22869", "type": "HCPCS" } ], "description": "Hc Insj Stablj Device Wo Dcmp 1Lv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 62648.3, "gross_charge": 96382.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101025", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22870", "type": "HCPCS" } ], "description": "Hc Insj Stablj Device Wo Dcmp 2Lv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31324.8, "gross_charge": 48192.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101026", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11424", "type": "HCPCS" } ], "description": "Hc Exc Ben Lesion S N H F G 3.1-4Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3935.75, "gross_charge": 6055.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101027", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "32408", "type": "HCPCS" } ], "description": "Hc Biopsy Lung Or Mediastinum Perc W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4928.3, "gross_charge": 7582.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101031", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55880", "type": "HCPCS" } ], "description": "Hc Hifu Ablation Prostate Transrectal W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11321.05, "gross_charge": 17417.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101032", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0613T", "type": "HCPCS" } ], "description": "Hc Percut Trnscath Interatrial Septal Shunt Device W Img Gud", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10746.45, "gross_charge": 16533.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101033", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0614T", "type": "HCPCS" } ], "description": "Hc Remve And Rplce Substernal Defib Pulse Generator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15613.0, "gross_charge": 24020.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101034", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0620T", "type": "HCPCS" } ], "description": "Hc Endvc Venous Arterialization Tibial Or Peronael Vein W Trnscth", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11374.35, "gross_charge": 17499.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101035", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0632T", "type": "HCPCS" } ], "description": "Hc Percut Trnscath Us Ablation Nervess Pulm Arteries Inc Right Hrt Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7976.15, "gross_charge": 12271.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101036", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9772", "type": "HCPCS" } ], "description": "Hc Revas Endo Lithotrip Tibial Peroneal Artery Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16444.35, "gross_charge": 25299.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101037", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9773", "type": "HCPCS" } ], "description": "Hc Revas Endo Lithotr Tib Per Stent Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18271.5, "gross_charge": 28110.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101038", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9774", "type": "HCPCS" } ], "description": "Hc Revas Endo Lithotr Atherectomy Tib Per Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18271.5, "gross_charge": 28110.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101039", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "C9775", "type": "HCPCS" } ], "description": "Hc Revas Endo Lithotr Atherectomy Tib Per Stent Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18271.5, "gross_charge": 28110.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101040", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33211", "type": "HCPCS" } ], "description": "Hc Insert Replc Temp Transvenous Dual Chamber Pacing Elect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7048.6, "gross_charge": 10844.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101041", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22867", "type": "HCPCS" } ], "description": "Hc Insj Stablj Device W Dcmp 1Lv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 62648.3, "gross_charge": 96382.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101042", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "22868", "type": "HCPCS" } ], "description": "Hc Insj Stablj Device W Dcmp 2Lv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31324.8, "gross_charge": 48192.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101043", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0442T", "type": "HCPCS" } ], "description": "Hc Cryoablation Nerve Plexus Or Truncal Nerve W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8785.4, "gross_charge": 13516.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101045", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28120", "type": "HCPCS" } ], "description": "Hc Excision Partial Bone Talus Calcaneus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3505.45, "gross_charge": 5393.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101046", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "23000", "type": "HCPCS" } ], "description": "Hc Removal Open Calcareous Deposits Subdeltoid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6708.65, "gross_charge": 10321.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101047", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "12020", "type": "HCPCS" } ], "description": "Hc Treatment Superficial Wound Dehiscence Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 596.7, "gross_charge": 918.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101048", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "12042", "type": "HCPCS" } ], "description": "Hc Intermediate Wnd Repair N H F G 2.6-7.0 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 811.2, "gross_charge": 1248.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101050", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64584", "type": "HCPCS" } ], "description": "Hc Removal Hypoglossal Nerve Nstim Ra Pulse Gen Respir Snr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11948.95, "gross_charge": 18383.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101051", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64628", "type": "HCPCS" } ], "description": "Hc Thermal Dstrct Intraosseous Bvn 1St 2 Lmbr Sac", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 62648.3, "gross_charge": 96382.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101053", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64629", "type": "HCPCS" } ], "description": "Hc Thermal Dstrct Intraosseous Bvn Ea Addtl Lmbr Sac", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 31324.8, "gross_charge": 48192.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101055", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0673T", "type": "HCPCS" } ], "description": "Hc Laser Ablation Benign Thyroid Nodule W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6895.2, "gross_charge": 10608.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101056", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0686T", "type": "HCPCS" } ], "description": "Hc Histotripsy Mal Hepatocellular Tiss W Img Gdn", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 25167.35, "gross_charge": 38719.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101058", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0707T", "type": "HCPCS" } ], "description": "Hc Inj Bone Sub Matrl Into Subchondral Bone Defect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5822.7, "gross_charge": 8958.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101059", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11401", "type": "HCPCS" } ], "description": "Hc Exc Bng Lsn Mrgs 0.6-1 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 824.2, "gross_charge": 1268.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101060", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28011", "type": "HCPCS" } ], "description": "Hc Tenotomy Perc Toe Multiple Tendons", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2068.3, "gross_charge": 3182.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101061", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "31502", "type": "HCPCS" } ], "description": "Hc Trach Tube Change", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1277.9, "gross_charge": 1966.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101062", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "38206", "type": "HCPCS" } ], "description": "Hc Harvest Auto Pbsc For Transplant Per Collect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4730.05, "gross_charge": 7277.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101063", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64646", "type": "HCPCS" } ], "description": "Hc Chemodenervation Of Trunk Muscle(S) 1-5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3733.6, "gross_charge": 5744.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101064", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64647", "type": "HCPCS" } ], "description": "Hc Chemodenervation Of Trunk Muscle(S) 6 Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3733.6, "gross_charge": 5744.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101065", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "52287", "type": "HCPCS" } ], "description": "Hc Cystourethroscopy Inj Chemodenervation Bladder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1800.5, "gross_charge": 2770.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101066", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38209", "type": "HCPCS" } ], "description": "Hc Thaw W/Wash Auto Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1783.6, "gross_charge": 2744.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101067", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38210", "type": "HCPCS" } ], "description": "Hc T-Cell Depletion Of Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1673.75, "gross_charge": 2575.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101068", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38211", "type": "HCPCS" } ], "description": "Hc Tumor Cell Depletion Of Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 438.1, "gross_charge": 674.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101069", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38212", "type": "HCPCS" } ], "description": "Hc Rbc Removal Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1673.75, "gross_charge": 2575.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101070", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "38214", "type": "HCPCS" } ], "description": "Hc Plasma Depletion Auto Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1673.75, "gross_charge": 2575.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101071", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "38215", "type": "HCPCS" } ], "description": "Hc Cell Concentration Auto Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1783.6, "gross_charge": 2744.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101072", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36836", "type": "HCPCS" } ], "description": "Hc Arteriovenous Fistula Creation Up Extrem Single Access Perc W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12982.45, "gross_charge": 19973.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101073", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "36837", "type": "HCPCS" } ], "description": "Hc Arteriovenous Fistula Creation Up Extrem Separate Access Perc W Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14487.2, "gross_charge": 22288.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101075", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11403", "type": "HCPCS" } ], "description": "Hc Exc Bng Lsn Mrgs 2.1-3.0 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1391.0, "gross_charge": 2140.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101076", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11404", "type": "HCPCS" } ], "description": "Hc Exc Bng Lsn Mrgs 3.1-4.0 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2687.75, "gross_charge": 4135.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101079", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64505", "type": "HCPCS" } ], "description": "Hc Injection Anes Agent Sphenopalatine Ganglion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 367.9, "gross_charge": 566.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101079_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64505", "type": "HCPCS" } ], "description": "Hc Injection Anes Agent Sphenopalatine Ganglion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 735.8, "gross_charge": 1132.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36101080", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33276", "type": "HCPCS" } ], "description": "Hc Insert Phrenic Nerve Stimulator System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20860.45, "gross_charge": 32093.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101081", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33277", "type": "HCPCS" } ], "description": "Hc Insert Phrenic Nerve Stim Transvenous Sensing Lead Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 975.0, "gross_charge": 1500.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101082", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33278", "type": "HCPCS" } ], "description": "Hc Remove Phrenic Nerve Stimulator System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6960.85, "gross_charge": 10709.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101083", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33279", "type": "HCPCS" } ], "description": "Hc Remove Phrenic Nerve Stim Transvenous Stim Or Sensing Lead(S) Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6327.75, "gross_charge": 9735.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101084", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33280", "type": "HCPCS" } ], "description": "Hc Remove Phrenic Nerve Stim Pulse Generator Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6327.75, "gross_charge": 9735.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101085", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33281", "type": "HCPCS" } ], "description": "Hc Reposition Phrenic Nerve Stim Transvenous Lead(S)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6327.75, "gross_charge": 9735.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101086", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33287", "type": "HCPCS" } ], "description": "Hc Remove & Replace Phrenic Nerve Stim Pulse Generator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13668.2, "gross_charge": 21028.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101087", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "33288", "type": "HCPCS" } ], "description": "Hc Remove & Replace Phrenic Nerve Stim Transvenous Stim Or Sensing Lead(S)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13668.2, "gross_charge": 21028.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101088", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0823T", "type": "HCPCS" } ], "description": "Hc Transcath Insert Perm Single Chamb Leadless Pacemaker Right Atrial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24159.2, "gross_charge": 37168.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101089", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0824T", "type": "HCPCS" } ], "description": "Hc Transcath Remove Perm Single Chamb Leadless Pacemaker Right Atrial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5928.0, "gross_charge": 9120.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101090", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0825T", "type": "HCPCS" } ], "description": "Hc Transcath Remove & Replace Perm Single Chamb Leadless Pacemaker Right Atrial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 24159.2, "gross_charge": 37168.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101091", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0861T", "type": "HCPCS" } ], "description": "Hc Remove Wireless Cardiac Stim Left Ventric Pacing Pulse Gen Both Components", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7302.75, "gross_charge": 11235.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101092", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0862T", "type": "HCPCS" } ], "description": "Hc Relocate Wireless Cardiac Stim Left Ventric Pacing Pulse Gen Battery Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3391.05, "gross_charge": 5217.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101093", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0863T", "type": "HCPCS" } ], "description": "Hc Relocate Wireless Cardiac Stim Left Ventric Pacing Pulse Gen Transmitter Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3391.05, "gross_charge": 5217.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101094", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "28039", "type": "HCPCS" } ], "description": "Hc Excise Tumor Soft Tis Foot/Toe 1.5Cm Or Greater", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4737.85, "gross_charge": 7289.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101095", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64999", "type": "HCPCS" } ], "description": "Hc Injection Anes Inferior Hypogastric Plexus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7134.4, "gross_charge": 10976.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101096", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64999", "type": "HCPCS" } ], "description": "Hc Injection Anes Prev Sacroiliac Fusion Site", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4228.9, "gross_charge": 6506.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101098", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "12041", "type": "HCPCS" } ], "description": "Hc Intermed Wnd Repair H N F G 2.5Cm Or Less", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 676.0, "gross_charge": 1040.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101099", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "57720", "type": "HCPCS" } ], "description": "Hc Trachelorrhaphy Plastic Repair Of Cervix", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3374.8, "gross_charge": 5192.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101100", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64605", "type": "HCPCS" } ], "description": "Hc Dest Neurolytc Trigeminal Nrv Supraorb Or Infraorb 2 Or 3 Div Brnch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3429.4, "gross_charge": 5276.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101100_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64605", "type": "HCPCS" } ], "description": "Hc Dest Neurolytc Trigeminal Nrv Supraorb Or Infraorb 2 Or 3 Div Brnch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6858.8, "gross_charge": 10552.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36101101", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "11443", "type": "HCPCS" } ], "description": "Hc Exc Ben Lesion Xcp Sk Tg F/E/E/N/L/M 2.1-3.0Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3935.75, "gross_charge": 6055.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101102", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0795T", "type": "HCPCS" } ], "description": "Hc Trcath Ins Perm Dual Chamb Leadless Pacer Comp System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17384.25, "gross_charge": 26745.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101103", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64486", "type": "HCPCS" } ], "description": "Hc Tap Block W Img Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3575.65, "gross_charge": 5501.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101104", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0441T", "type": "HCPCS" } ], "description": "Hc Abltj Perc Cryoabltj Img Gdn Lxtr/Perph Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4115.15, "gross_charge": 6331.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101104_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0441T", "type": "HCPCS" } ], "description": "Hc Abltj Perc Cryoabltj Img Gdn Lxtr/Perph Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 8230.3, "gross_charge": 12662.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36101105", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64488", "type": "HCPCS" } ], "description": "Hc Tap Block W Img Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7151.3, "gross_charge": 11002.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101106", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64466", "type": "HCPCS" } ], "description": "Hc Thoracic Fascial Plane Block W Img Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3575.65, "gross_charge": 5501.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101108", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64468", "type": "HCPCS" } ], "description": "Hc Thoracic Fascial Plane Block W Img Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7151.3, "gross_charge": 11002.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101110", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64473", "type": "HCPCS" } ], "description": "Hc Le Fascial Plane Block W Img Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3575.65, "gross_charge": 5501.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101110_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64473", "type": "HCPCS" } ], "description": "Hc Le Fascial Plane Block W Img Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 7151.3, "gross_charge": 11002.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "36101112", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0915T", "type": "HCPCS" } ], "description": "Hc Insert Perm Ccm-D Sys Pulse Gen & Eltrds", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15613.0, "gross_charge": 24020.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101113", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0916T", "type": "HCPCS" } ], "description": "Hc Insert Perm Ccm-D Sys Pulse Gen Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14311.7, "gross_charge": 22018.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101114", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0917T", "type": "HCPCS" } ], "description": "Hc Insert Perm Ccm-D Sys 1 Lead Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11951.55, "gross_charge": 18387.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101115", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0918T", "type": "HCPCS" } ], "description": "Hc Insert Perm Ccm-D Sys Dual Leads Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11951.55, "gross_charge": 18387.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101116", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0919T", "type": "HCPCS" } ], "description": "Hc Remove Perm Ccm-D Sys Pulse Gen Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9591.4, "gross_charge": 14756.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101117", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0920T", "type": "HCPCS" } ], "description": "Hc Remove Perm Ccm-D Sys 1 Pacing Lead Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9591.4, "gross_charge": 14756.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101118", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0921T", "type": "HCPCS" } ], "description": "Hc Remove Perm Ccm-D Sys 1 Defib Lead Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9591.4, "gross_charge": 14756.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101119", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0922T", "type": "HCPCS" } ], "description": "Hc Remove Perm Ccm-D Sys Dual Leads Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9591.4, "gross_charge": 14756.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101120", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0923T", "type": "HCPCS" } ], "description": "Hc Remove & Replace Perm Ccm-D Pulse Gen Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14311.7, "gross_charge": 22018.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101121", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0924T", "type": "HCPCS" } ], "description": "Hc Reposition Prev Ccm-D Electrodes/ Leads", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1629.55, "gross_charge": 2507.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101122", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0925T", "type": "HCPCS" } ], "description": "Hc Relocate Skin Pocket Ccm-D Pulse Gen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4821.05, "gross_charge": 7417.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101123", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0930T", "type": "HCPCS" } ], "description": "Hc Ephys Eval Ccm-D Ld At Initial Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3199.3, "gross_charge": 4922.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101124", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0933T", "type": "HCPCS" } ], "description": "Hc Transcath Implant Wrls Lt Atr Prs Snsr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7586.15, "gross_charge": 11671.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101125", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "10081", "type": "HCPCS" } ], "description": "Hc I And D Pilonidal Cyst Complicated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1241.5, "gross_charge": 1910.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101129", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "0931T", "type": "HCPCS" } ], "description": "Hc Ephys Eval Ccm-D Ld Separate From Date Of Insert", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3199.3, "gross_charge": 4922.0, "setting": "both" } ] }, { "code_information": [ { "code": "36101130", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "34716", "type": "HCPCS" } ], "description": "Hc Open Axillary/Subclavian Art Expos W/Conduit Crtj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 892.45, "gross_charge": 1373.0, "setting": "both" } ] }, { "code_information": [ { "code": "37000004", "type": "CDM" }, { "code": "370", "type": "RC" }, { "code": "99153", "type": "HCPCS" } ], "description": "Hc Mod Sed Same Phys As Proc Addl 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 389.35, "gross_charge": 599.0, "setting": "both" } ] }, { "code_information": [ { "code": "37000008", "type": "CDM" }, { "code": "370", "type": "RC" }, { "code": "99157", "type": "HCPCS" } ], "description": "Hc Mod Sed Other Provider Than Proc Addl 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 389.35, "gross_charge": 599.0, "setting": "both" } ] }, { "code_information": [ { "code": "37000010", "type": "CDM" }, { "code": "370", "type": "RC" }, { "code": "99151", "type": "HCPCS" } ], "description": "Hc Mod Sed Same Phys As Proc Up To 5 Yrs 1St 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 389.35, "gross_charge": 599.0, "setting": "both" } ] }, { "code_information": [ { "code": "37000011", "type": "CDM" }, { "code": "370", "type": "RC" }, { "code": "99152", "type": "HCPCS" } ], "description": "Hc Mod Sed Same Phys As Proc 1St 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 389.35, "gross_charge": 599.0, "setting": "both" } ] }, { "code_information": [ { "code": "37000013", "type": "CDM" }, { "code": "370", "type": "RC" }, { "code": "99155", "type": "HCPCS" } ], "description": "Hc Mod Sed Dif Phys As Proc Up To 5 Yrs 1St 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 389.35, "gross_charge": 599.0, "setting": "both" } ] }, { "code_information": [ { "code": "37000014", "type": "CDM" }, { "code": "370", "type": "RC" }, { "code": "99156", "type": "HCPCS" } ], "description": "Hc Mod Sed Other Provider Than Proc 1St 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 389.35, "gross_charge": 599.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000001", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9010", "type": "HCPCS" } ], "description": "Hc Whole Blood 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1626.95, "gross_charge": 2503.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000004", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9012", "type": "HCPCS" } ], "description": "Hc Cryoprecipitate 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 236.6, "gross_charge": 364.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000007", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9016", "type": "HCPCS" } ], "description": "Hc Red Cells Leuko Reduced 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 638.3, "gross_charge": 982.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000008", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9017", "type": "HCPCS" } ], "description": "Hc Fresh Frozen Plasma 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 142.35, "gross_charge": 219.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000012", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9021", "type": "HCPCS" } ], "description": "Hc Red Cells Packed 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 669.5, "gross_charge": 1030.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000013", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9022", "type": "HCPCS" } ], "description": "Hc Red Cells Washed 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1348.1, "gross_charge": 2074.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000014", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9031", "type": "HCPCS" } ], "description": "Hc Platelets Leuko Reduced Directed 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 329.55, "gross_charge": 507.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000015", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9031", "type": "HCPCS" } ], "description": "Hc Platelets Leuko Reduced 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2878.2, "gross_charge": 4428.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000016", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9033", "type": "HCPCS" } ], "description": "Hc Platelets Leuko Reduced Irradiated 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 276.25, "gross_charge": 425.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000017", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9035", "type": "HCPCS" } ], "description": "Hc Platelets Pheresis Leukocyte Reduced 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1990.95, "gross_charge": 3063.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000018", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9037", "type": "HCPCS" } ], "description": "Hc Platelets Pheresis L R Irradiated 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2139.15, "gross_charge": 3291.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000019", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9040", "type": "HCPCS" } ], "description": "Hc Red Cells Leuko Reduced Irradiated 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 786.5, "gross_charge": 1210.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000025", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9054", "type": "HCPCS" } ], "description": "Hc Red Cells Frozen Deglycerol Lr Washed 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1762.15, "gross_charge": 2711.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000029", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9073", "type": "HCPCS" } ], "description": "Hc Platelets, Pheresis, Pathogen-Reduced, Each Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2198.3, "gross_charge": 3382.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000030", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9017", "type": "HCPCS" } ], "description": "Hc Fresh Frozen Plasma 1 Unit <8Hrs Covid19 Research", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 55.25, "gross_charge": 85.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000032", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9025", "type": "HCPCS" } ], "description": "Hc Plasma, Cryoprecipitate Reduced, Pathogen Reduced, Each Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 88.4, "gross_charge": 136.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000033", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9026", "type": "HCPCS" } ], "description": "Hc Cryoprecipitated Fibrinogen Complex, Pathogen Reduced, Each Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 204.1, "gross_charge": 314.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000034", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9050", "type": "HCPCS" } ], "description": "Hc Granulocytes, Pheresis, Each Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8396.7, "gross_charge": 12918.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000035", "type": "CDM" }, { "code": "300", "type": "RC" }, { "code": "0219U", "type": "HCPCS" } ], "description": "Hc Nfct Agent Hiv Trgt Viral Next-Gnrj Seq Alys Alg So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 835.9, "gross_charge": 1286.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000036", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9021", "type": "HCPCS" } ], "description": "Hc Autologous Blood Product 1 Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1181.7, "gross_charge": 1818.0, "setting": "both" } ] }, { "code_information": [ { "code": "39000037", "type": "CDM" }, { "code": "390", "type": "RC" }, { "code": "P9052", "type": "HCPCS" } ], "description": "Hc Platelets, Hla-Matched Leukocyte Reduced, Apheresis/Pheresis, Each Unit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1925.3, "gross_charge": 2962.0, "setting": "both" } ] }, { "code_information": [ { "code": "39100001", "type": "CDM" }, { "code": "391", "type": "RC" }, { "code": "36430", "type": "HCPCS" } ], "description": "Hc Transfuse Blood Products Level I", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1385.15, "gross_charge": 2131.0, "setting": "both" } ] }, { "code_information": [ { "code": "39100002", "type": "CDM" }, { "code": "391", "type": "RC" }, { "code": "36460", "type": "HCPCS" } ], "description": "Hc Transfusion Fetal Intrauterine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 679.25, "gross_charge": 1045.0, "setting": "both" } ] }, { "code_information": [ { "code": "39100003", "type": "CDM" }, { "code": "391", "type": "RC" }, { "code": "36430", "type": "HCPCS" } ], "description": "Hc Transfuse Blood Products Level Ii", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1800.5, "gross_charge": 2770.0, "setting": "both" } ] }, { "code_information": [ { "code": "39100004", "type": "CDM" }, { "code": "391", "type": "RC" }, { "code": "36430", "type": "HCPCS" } ], "description": "Hc Transfuse Blood Products Level Iii", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2215.85, "gross_charge": 3409.0, "setting": "both" } ] }, { "code_information": [ { "code": "40100004", "type": "CDM" }, { "code": "401", "type": "RC" }, { "code": "77066", "type": "HCPCS" } ], "description": "Hc Mammogram Diag Bilat Digital W Cad", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 540.8, "gross_charge": 832.0, "setting": "both" } ] }, { "code_information": [ { "code": "40100005", "type": "CDM" }, { "code": "401", "type": "RC" }, { "code": "77065", "type": "HCPCS" } ], "description": "Hc Mammogram Diag Unilat Digital W Cad", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 482.3, "gross_charge": 742.0, "setting": "both" } ] }, { "code_information": [ { "code": "40100007", "type": "CDM" }, { "code": "401", "type": "RC" }, { "code": "77061", "type": "HCPCS" } ], "description": "Hc Tomosynthesis Diag Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "40100008", "type": "CDM" }, { "code": "401", "type": "RC" }, { "code": "77062", "type": "HCPCS" } ], "description": "Hc Tomosynthesis Diag Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200001", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76506", "type": "HCPCS" } ], "description": "Hc Encephalogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 225.55, "gross_charge": 347.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200002", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76536", "type": "HCPCS" } ], "description": "Hc Us Soft Tissue Head And Neck", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 478.4, "gross_charge": 736.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200003", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76604", "type": "HCPCS" } ], "description": "Hc Us Chest", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 247.65, "gross_charge": 381.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200005", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76700", "type": "HCPCS" } ], "description": "Hc Us Abdomen Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 403.0, "gross_charge": 620.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200006", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76705", "type": "HCPCS" } ], "description": "Hc Us Abdomen Limited", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 354.9, "gross_charge": 546.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200007", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76770", "type": "HCPCS" } ], "description": "Hc Us Retroperitioneal Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 438.75, "gross_charge": 675.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200008", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76775", "type": "HCPCS" } ], "description": "Hc Us Retroperitioneal Limited", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 321.1, "gross_charge": 494.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200009", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76800", "type": "HCPCS" } ], "description": "Hc Us Spinal Canal And Contents", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 536.9, "gross_charge": 826.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200010", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76801", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus 1St Trimester Sgl Fetus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 300.95, "gross_charge": 463.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200011", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76802", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus 1St Trimester Ea Addl Fetus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 178.75, "gross_charge": 275.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200012", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76805", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus After 1St Trimester Sgl Fetus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 332.8, "gross_charge": 512.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200013", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76810", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus After 1St Trimester Ea Addl Fetus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 215.15, "gross_charge": 331.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200014", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76811", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus W Detail Fetal Anatomy Sgl Fetus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 446.55, "gross_charge": 687.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200015", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76812", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus W Detail Fetal Anatomy Addl Fetus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 168.35, "gross_charge": 259.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200016", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76813", "type": "HCPCS" } ], "description": "Hc Us Fetal Nuchal Translucency Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 147.55, "gross_charge": 227.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200017", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76814", "type": "HCPCS" } ], "description": "Hc Us Fetal Nuchal Translucency Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200018", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76815", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus Limited 1 Or More Fetuses", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 137.15, "gross_charge": 211.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200019", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76816", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus Follow Up Per Fetus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 212.55, "gross_charge": 327.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200020", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76817", "type": "HCPCS" } ], "description": "Hc Us Pregnant Uterus Transvaginal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 284.7, "gross_charge": 438.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200021", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76818", "type": "HCPCS" } ], "description": "Hc Us Fetal Biophysical Profile W Nst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 268.45, "gross_charge": 413.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200022", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76819", "type": "HCPCS" } ], "description": "Hc Us Fetal Biophysical Profile Wo Nst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 244.4, "gross_charge": 376.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200023", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76820", "type": "HCPCS" } ], "description": "Hc Us Velocimetry Umbilical Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 157.95, "gross_charge": 243.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200024", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76821", "type": "HCPCS" } ], "description": "Hc Us Velocimetry Fetal Middle Cerebral Artery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.95, "gross_charge": 223.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200025", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76825", "type": "HCPCS" } ], "description": "Hc Fetal Heart Echo 2D W Wo M Mode Recording", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 623.35, "gross_charge": 959.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200026", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76826", "type": "HCPCS" } ], "description": "Hc Fetal Heart Echo 2D W Wo M Mode Follow Up", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 224.25, "gross_charge": 345.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200027", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76827", "type": "HCPCS" } ], "description": "Hc Fetal Heart Echo Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 390.0, "gross_charge": 600.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200028", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76828", "type": "HCPCS" } ], "description": "Hc Fetal Heart Echo Follow Up", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 127.4, "gross_charge": 196.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200029", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76830", "type": "HCPCS" } ], "description": "Hc Us Transvaginal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 427.7, "gross_charge": 658.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200030", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76831", "type": "HCPCS" } ], "description": "Hc Sonohystogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 405.6, "gross_charge": 624.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200031", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76856", "type": "HCPCS" } ], "description": "Hc Us Pelvis Non Ob Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 225.55, "gross_charge": 347.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200032", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76857", "type": "HCPCS" } ], "description": "Hc Us Pelvis Non Ob Limited Follow Up", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 183.3, "gross_charge": 282.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200033", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76870", "type": "HCPCS" } ], "description": "Hc Us Scrotum", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 399.75, "gross_charge": 615.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200034", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76872", "type": "HCPCS" } ], "description": "Hc Us Transrectal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 421.2, "gross_charge": 648.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200035", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76873", "type": "HCPCS" } ], "description": "Hc Us Prostate Volume Study For Brachytherapy Planning", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 445.25, "gross_charge": 685.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200036", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76881", "type": "HCPCS" } ], "description": "Hc Us Extremity Complete Joint", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 433.55, "gross_charge": 667.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200037", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76882", "type": "HCPCS" } ], "description": "Hc Us Extremity Limited Joint Or Non Vasc Structure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 278.85, "gross_charge": 429.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200040", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76936", "type": "HCPCS" } ], "description": "Hc Us Guided Compression Repair", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 337.35, "gross_charge": 519.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200041", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76937", "type": "HCPCS" } ], "description": "Hc Us Guided Vascular Access", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 280.15, "gross_charge": 431.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200042", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76940", "type": "HCPCS" } ], "description": "Hc Us Guided Parenchymal Tissue Ablation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 174.2, "gross_charge": 268.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200043", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76942", "type": "HCPCS" } ], "description": "Hc Us Guided Needle Placement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 441.35, "gross_charge": 679.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200044", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76945", "type": "HCPCS" } ], "description": "Hc Us Guided Chorionic Villus Sampling", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200045", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76946", "type": "HCPCS" } ], "description": "Hc Us Guided Amniocentesis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 174.85, "gross_charge": 269.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200046", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76965", "type": "HCPCS" } ], "description": "Hc Us Guided Interstitial Radioelement Application", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 427.7, "gross_charge": 658.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200048", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76998", "type": "HCPCS" } ], "description": "Hc Us Intraoperative", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 386.1, "gross_charge": 594.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200049", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76999", "type": "HCPCS" } ], "description": "Hc Unlisted Ultrasound Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 354.9, "gross_charge": 546.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200051", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76706", "type": "HCPCS" } ], "description": "Hc Us For Aaa Screening", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 150.15, "gross_charge": 231.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200054", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76641", "type": "HCPCS" } ], "description": "Hc Us Breast Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 610.35, "gross_charge": 939.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200054_50", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76641", "type": "HCPCS" } ], "description": "Hc Us Breast Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1220.7, "gross_charge": 1878.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "40200055", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76642", "type": "HCPCS" } ], "description": "Hc Us Breast Limited", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 464.75, "gross_charge": 715.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200055_50", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76642", "type": "HCPCS" } ], "description": "Hc Us Breast Limited", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 924.3, "gross_charge": 1422.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "40200057", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76641", "type": "HCPCS" } ], "description": "Hc Us Screening Breast Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 146.25, "gross_charge": 225.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200057_50", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76641", "type": "HCPCS" } ], "description": "Hc Us Screening Breast Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 292.5, "gross_charge": 450.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "40200058", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76941", "type": "HCPCS" } ], "description": "Hc Us Guidance Cordocentesis Or Fetal Transfusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 259.35, "gross_charge": 399.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200060", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76641", "type": "HCPCS" } ], "description": "Hc Us Screening Breast Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 292.5, "gross_charge": 450.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200061", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "76981", "type": "HCPCS" } ], "description": "Hc Us Elastography Parenchyma (Organ)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 313.95, "gross_charge": 483.0, "setting": "both" } ] }, { "code_information": [ { "code": "40200066", "type": "CDM" }, { "code": "402", "type": "RC" }, { "code": "91200", "type": "HCPCS" } ], "description": "Hc Elastography Liver Wo Img", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 355.55, "gross_charge": 547.0, "setting": "both" } ] }, { "code_information": [ { "code": "40300003", "type": "CDM" }, { "code": "403", "type": "RC" }, { "code": "77067", "type": "HCPCS" } ], "description": "Hc Mammogram Screening Digital W Cad", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 160.55, "gross_charge": 247.0, "setting": "both" } ] }, { "code_information": [ { "code": "40300004", "type": "CDM" }, { "code": "403", "type": "RC" }, { "code": "77063", "type": "HCPCS" } ], "description": "Hc Tomosynthesis Screening Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.9, "gross_charge": 66.0, "setting": "both" } ] }, { "code_information": [ { "code": "40400003", "type": "CDM" }, { "code": "404", "type": "RC" }, { "code": "78608", "type": "HCPCS" } ], "description": "Hc Brain Imaging Pet Metabolic Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4603.95, "gross_charge": 7083.0, "setting": "both" } ] }, { "code_information": [ { "code": "40400004", "type": "CDM" }, { "code": "404", "type": "RC" }, { "code": "78815", "type": "HCPCS" } ], "description": "Hc Pet Imaging W Ct Skull Base To Mid Thigh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4977.05, "gross_charge": 7657.0, "setting": "both" } ] }, { "code_information": [ { "code": "40400005", "type": "CDM" }, { "code": "404", "type": "RC" }, { "code": "78816", "type": "HCPCS" } ], "description": "Hc Pet Imaging W Ct Whole Body", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6000.8, "gross_charge": 9232.0, "setting": "both" } ] }, { "code_information": [ { "code": "40400008", "type": "CDM" }, { "code": "404", "type": "RC" }, { "code": "78814", "type": "HCPCS" } ], "description": "Hc Pet Imaging W Ct Limited Area", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4086.55, "gross_charge": 6287.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000004", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94002", "type": "HCPCS" } ], "description": "Hc Ventilator Init Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1653.6, "gross_charge": 2544.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000008", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94003", "type": "HCPCS" } ], "description": "Hc Ventilator Subq Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 950.3, "gross_charge": 1462.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000014", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94640", "type": "HCPCS" } ], "description": "Hc Inhalation Treatment For Aao Or Sputum Induction", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.05, "gross_charge": 377.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000024", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94642", "type": "HCPCS" } ], "description": "Hc Pentamidine Aerosol Inhalation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1413.1, "gross_charge": 2174.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000025", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94644", "type": "HCPCS" } ], "description": "Hc Cont Inhal Tx W Aerosol 1St Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 767.0, "gross_charge": 1180.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000026", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94645", "type": "HCPCS" } ], "description": "Hc Cont Inhal Tx W Aerosol Ea Addl H", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 471.25, "gross_charge": 725.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000027", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94660", "type": "HCPCS" } ], "description": "Hc Cpap Bipap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 528.45, "gross_charge": 813.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000031", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94660", "type": "HCPCS" } ], "description": "Hc Pts Own Cpap Bipap Init Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 244.4, "gross_charge": 376.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000032", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94660", "type": "HCPCS" } ], "description": "Hc Pts Own Cpap Bipap Subseq Day", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 244.4, "gross_charge": 376.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000033", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94664", "type": "HCPCS" } ], "description": "Hc Mdi Instruction Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 364.0, "gross_charge": 560.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000035", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94667", "type": "HCPCS" } ], "description": "Hc Postural Drainage Percussion Init", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 318.5, "gross_charge": 490.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000040", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94668", "type": "HCPCS" } ], "description": "Hc Postural Drainage Percussion Subseq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.2, "gross_charge": 408.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000043", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "94669", "type": "HCPCS" } ], "description": "Hc Pulm Vest Therapy Each Session", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 364.0, "gross_charge": 560.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000044", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "G0237", "type": "HCPCS" } ], "description": "Hc Respiratory Therapy One On One 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.3, "gross_charge": 122.0, "setting": "both" } ] }, { "code_information": [ { "code": "41000045", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94610", "type": "HCPCS" } ], "description": "Hc Surfactant Administered Through Et Tube", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "41300001", "type": "CDM" }, { "code": "413", "type": "RC" }, { "code": "G0277", "type": "HCPCS" } ], "description": "Hc Hyperbaric Oxygen Full Body Per 30Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1311.05, "gross_charge": 2017.0, "setting": "both" } ] }, { "code_information": [ { "code": "41900001", "type": "CDM" }, { "code": "419", "type": "RC" }, { "code": "G0239", "type": "HCPCS" } ], "description": "Hc Improve Resp Fxn Other Group", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 346.45, "gross_charge": 533.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000001", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29405", "type": "HCPCS" } ], "description": "Hc Application Short Leg Cast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 847.6, "gross_charge": 1304.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000001_50", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29405", "type": "HCPCS" } ], "description": "Hc Application Short Leg Cast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1695.2, "gross_charge": 2608.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "42000002", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29425", "type": "HCPCS" } ], "description": "Hc Application Short Leg Cast Walking", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 823.55, "gross_charge": 1267.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000002_50", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29425", "type": "HCPCS" } ], "description": "Hc Application Short Leg Cast Walking", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1647.1, "gross_charge": 2534.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "42000005", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "95992", "type": "HCPCS" } ], "description": "Hc Pt Canalith Respositioning Proc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 197.6, "gross_charge": 304.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000007", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97012", "type": "HCPCS" } ], "description": "Hc Pt Traction Mechanical", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 68.25, "gross_charge": 105.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000008", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97016", "type": "HCPCS" } ], "description": "Hc Pt Vasopneumatic Treatment", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.25, "gross_charge": 125.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000009", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97018", "type": "HCPCS" } ], "description": "Hc Pt Paraffin Bath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69.55, "gross_charge": 107.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000012", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97022", "type": "HCPCS" } ], "description": "Hc Pt Fluidotherapy Or Whirlpool", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000014", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97032", "type": "HCPCS" } ], "description": "Hc Pt Electrical Stim Attended 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 131.95, "gross_charge": 203.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000015", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97033", "type": "HCPCS" } ], "description": "Hc Pt Iontophoresis 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 132.6, "gross_charge": 204.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000016", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97034", "type": "HCPCS" } ], "description": "Hc Pt Contrast Bath 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 113.1, "gross_charge": 174.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000017", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97035", "type": "HCPCS" } ], "description": "Hc Pt Ultrasound 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 68.9, "gross_charge": 106.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000018", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97110", "type": "HCPCS" } ], "description": "Hc Pt Exercise Therapeutic 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 125.45, "gross_charge": 193.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000019", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97112", "type": "HCPCS" } ], "description": "Hc Pt Neuromuscular Reeducation 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.25, "gross_charge": 165.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000020", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97113", "type": "HCPCS" } ], "description": "Hc Pt Aquatic Therapy Exercise 15Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000021", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97116", "type": "HCPCS" } ], "description": "Hc Pt Gait Training 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 122.85, "gross_charge": 189.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000022", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97124", "type": "HCPCS" } ], "description": "Hc Pt Therapeutic Massage 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.3, "gross_charge": 122.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000023", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97140", "type": "HCPCS" } ], "description": "Hc Pt Manual Therapy 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.7, "gross_charge": 198.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000024", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97150", "type": "HCPCS" } ], "description": "Hc Pt Group Exercise", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000025", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97530", "type": "HCPCS" } ], "description": "Hc Pt Functional Activity 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 123.5, "gross_charge": 190.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000026", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97533", "type": "HCPCS" } ], "description": "Hc Pt Sensory Integration 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 104.65, "gross_charge": 161.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000027", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97535", "type": "HCPCS" } ], "description": "Hc Pt Self Care Home Mangagement 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 113.1, "gross_charge": 174.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000028", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97537", "type": "HCPCS" } ], "description": "Hc Pt Community Work Reintegration 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.85, "gross_charge": 129.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000029", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97542", "type": "HCPCS" } ], "description": "Hc Pt Wheelchair Training 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 88.4, "gross_charge": 136.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000030", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97545", "type": "HCPCS" } ], "description": "Hc Pt Work Harden Conditioning Init 2Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 152.75, "gross_charge": 235.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000031", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97546", "type": "HCPCS" } ], "description": "Hc Pt Work Harden Conditioning Ea Addl Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 75.4, "gross_charge": 116.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000032", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97597", "type": "HCPCS" } ], "description": "Hc Removal Devitalized Tissue Up To 20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 822.25, "gross_charge": 1265.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000033", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97598", "type": "HCPCS" } ], "description": "Hc Removal Devitalized Tissue Ea Addl 20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.05, "gross_charge": 377.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000034", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97750", "type": "HCPCS" } ], "description": "Hc Pt Performance Test 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 103.35, "gross_charge": 159.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000035", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97760", "type": "HCPCS" } ], "description": "Hc Pt Initial Orthotic Fitting Training 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000036", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97761", "type": "HCPCS" } ], "description": "Hc Pt Initial Prosthetic Training 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 104.65, "gross_charge": 161.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000038", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "G0283", "type": "HCPCS" } ], "description": "Hc Pt Electrical Stim Unattended", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.05, "gross_charge": 197.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000041", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "W0637", "type": "HCPCS" } ], "description": "Hc Pt Bwc Transitional Work 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.95, "gross_charge": 103.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000042", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "W0644", "type": "HCPCS" } ], "description": "Hc Pt Bwc Ergonomic Study 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 93.6, "gross_charge": 144.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000043", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "W0645", "type": "HCPCS" } ], "description": "Hc Pt Job Analysis 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 93.6, "gross_charge": 144.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000049", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "W0710", "type": "HCPCS" } ], "description": "Hc Pt Bwc Work Conditioning Per 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000123", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "96110", "type": "HCPCS" } ], "description": "Hc Pt Developmental Screening", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 165.1, "gross_charge": 254.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000125", "type": "CDM" }, { "code": "420", "type": "RC" } ], "description": "Hc Pt Tx Cpt 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000126", "type": "CDM" }, { "code": "420", "type": "RC" } ], "description": "Hc Pt Eval Epv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.9, "gross_charge": 166.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000129", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97763", "type": "HCPCS" } ], "description": "Hc Pt Subsequent Orthotic Prosthetic Check 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.9, "gross_charge": 166.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000130", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "99366", "type": "HCPCS" } ], "description": "Hc Pt Rehab Family Conference - 30 Min Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000131", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "96112", "type": "HCPCS" } ], "description": "Hc Pt Developmental Testing, First Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 433.55, "gross_charge": 667.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000132", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "96113", "type": "HCPCS" } ], "description": "Hc Pt Developmental Testing, Ea Add 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 216.45, "gross_charge": 333.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000136", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29581", "type": "HCPCS" } ], "description": "Hc Pt Applic Multi Layer Comp Sys Leg/Ankle/Foot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 609.7, "gross_charge": 938.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000136_50", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29581", "type": "HCPCS" } ], "description": "Hc Pt Applic Multi Layer Comp Sys Leg/Ankle/Foot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1219.4, "gross_charge": 1876.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "42000137", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29584", "type": "HCPCS" } ], "description": "Hc Pt Applic Multi Layer Comp Sys Arm/Hand/Fingers", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 731.9, "gross_charge": 1126.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000137_50", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "29584", "type": "HCPCS" } ], "description": "Hc Pt Applic Multi Layer Comp Sys Arm/Hand/Fingers", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1463.8, "gross_charge": 2252.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "42000138", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "G0281", "type": "HCPCS" } ], "description": "Hc Pt E-Stim Unattend For Chronic Ulcers", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.05, "gross_charge": 197.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000139", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97550", "type": "HCPCS" } ], "description": "Hc Pt Caregiver Training Initial 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 228.8, "gross_charge": 352.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000140", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97551", "type": "HCPCS" } ], "description": "Hc Pt Caregiver Training Ea Addl 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "42000141", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "97552", "type": "HCPCS" } ], "description": "Hc Pt Caregiver Training Group", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.85, "gross_charge": 89.0, "setting": "both" } ] }, { "code_information": [ { "code": "42400005", "type": "CDM" }, { "code": "424", "type": "RC" }, { "code": "97161", "type": "HCPCS" } ], "description": "Hc Pt Eval Low Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 278.2, "gross_charge": 428.0, "setting": "both" } ] }, { "code_information": [ { "code": "42400006", "type": "CDM" }, { "code": "424", "type": "RC" }, { "code": "97162", "type": "HCPCS" } ], "description": "Hc Pt Eval Moderate Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 302.25, "gross_charge": 465.0, "setting": "both" } ] }, { "code_information": [ { "code": "42400007", "type": "CDM" }, { "code": "424", "type": "RC" }, { "code": "97163", "type": "HCPCS" } ], "description": "Hc Pt Eval High Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 326.95, "gross_charge": 503.0, "setting": "both" } ] }, { "code_information": [ { "code": "42400008", "type": "CDM" }, { "code": "424", "type": "RC" }, { "code": "97164", "type": "HCPCS" } ], "description": "Hc Pt Re-Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 180.05, "gross_charge": 277.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000001", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29065", "type": "HCPCS" } ], "description": "Hc Application Cast Long Arm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 276.25, "gross_charge": 425.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000001_50", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29065", "type": "HCPCS" } ], "description": "Hc Application Cast Long Arm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 552.5, "gross_charge": 850.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "43000002", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29075", "type": "HCPCS" } ], "description": "Hc Application Cast Short Arm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 276.25, "gross_charge": 425.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000002_50", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29075", "type": "HCPCS" } ], "description": "Hc Application Cast Short Arm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 552.5, "gross_charge": 850.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "43000003", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29085", "type": "HCPCS" } ], "description": "Hc Application Cast Hand Or Wrist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 397.8, "gross_charge": 612.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000003_50", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29085", "type": "HCPCS" } ], "description": "Hc Application Cast Hand Or Wrist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 795.6, "gross_charge": 1224.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "43000004", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29086", "type": "HCPCS" } ], "description": "Hc Application Cast Finger", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 200.2, "gross_charge": 308.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000004_50", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29086", "type": "HCPCS" } ], "description": "Hc Application Cast Finger", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 400.4, "gross_charge": 616.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "43000005", "type": "CDM" }, { "code": "430", "type": "RC" } ], "description": "Hc Drive Com/Wk Reint 15Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18.85, "gross_charge": 29.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000006", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "G0129", "type": "HCPCS" } ], "description": "Hc Php Ot Per Session 45 Min Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 339.95, "gross_charge": 523.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000008", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "W0644", "type": "HCPCS" } ], "description": "Hc Ot Bwc Ergonomic Study Per 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 93.6, "gross_charge": 144.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000009", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "96125", "type": "HCPCS" } ], "description": "Hc Standard Cognitive Performance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 191.1, "gross_charge": 294.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000012", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "96110", "type": "HCPCS" } ], "description": "Hc Ot Developmental Screening", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 165.1, "gross_charge": 254.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000014", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97016", "type": "HCPCS" } ], "description": "Hc Ot Vasopneumatic Treatment", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 81.25, "gross_charge": 125.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000015", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97018", "type": "HCPCS" } ], "description": "Hc Ot Paraffin Bath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 69.55, "gross_charge": 107.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000016", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97022", "type": "HCPCS" } ], "description": "Hc Ot Fluidotherapy Or Whirlpool", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000017", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97032", "type": "HCPCS" } ], "description": "Hc Ot Electrical Stim Attended 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 131.95, "gross_charge": 203.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000018", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97033", "type": "HCPCS" } ], "description": "Hc Ot Iontophoresis 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 132.6, "gross_charge": 204.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000019", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97034", "type": "HCPCS" } ], "description": "Hc Ot Contrast Bath 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 113.1, "gross_charge": 174.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000020", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97035", "type": "HCPCS" } ], "description": "Hc Ot Ultrasound 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 68.9, "gross_charge": 106.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000021", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97110", "type": "HCPCS" } ], "description": "Hc Ot Exercise Therapeutic 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 125.45, "gross_charge": 193.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000022", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97112", "type": "HCPCS" } ], "description": "Hc Ot Neuromuscular Reeducation 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.25, "gross_charge": 165.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000023", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97113", "type": "HCPCS" } ], "description": "Hc Ot Aquatic Therapy Exercise 15Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000024", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97124", "type": "HCPCS" } ], "description": "Hc Ot Therapeutic Massage 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.3, "gross_charge": 122.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000025", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97140", "type": "HCPCS" } ], "description": "Hc Ot Manual Therapy 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.7, "gross_charge": 198.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000026", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97150", "type": "HCPCS" } ], "description": "Hc Ot Group Exercise", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000027", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97530", "type": "HCPCS" } ], "description": "Hc Ot Functional Activity 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 123.5, "gross_charge": 190.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000028", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97533", "type": "HCPCS" } ], "description": "Hc Ot Sensory Integration 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 104.65, "gross_charge": 161.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000029", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97535", "type": "HCPCS" } ], "description": "Hc Ot Self Care Home Mangagement 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 113.1, "gross_charge": 174.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000030", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97537", "type": "HCPCS" } ], "description": "Hc Ot Community Work Reintegration 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.85, "gross_charge": 129.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000032", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97542", "type": "HCPCS" } ], "description": "Hc Ot Wheelchair Training 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 88.4, "gross_charge": 136.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000033", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97545", "type": "HCPCS" } ], "description": "Hc Ot Work Harden Conditioning Init 2Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 152.75, "gross_charge": 235.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000035", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97597", "type": "HCPCS" } ], "description": "Hc Ot Removal Devitalized Tissue Up To 20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 986.7, "gross_charge": 1518.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000036", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97598", "type": "HCPCS" } ], "description": "Hc Ot Removal Devitalized Tissue Ea Addl 20 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 245.05, "gross_charge": 377.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000037", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97750", "type": "HCPCS" } ], "description": "Hc Ot Performance Test 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 103.35, "gross_charge": 159.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000038", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97760", "type": "HCPCS" } ], "description": "Hc Ot Initial Orthotic Fitting Training 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.75, "gross_charge": 215.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000039", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97761", "type": "HCPCS" } ], "description": "Hc Ot Initial Prosthetic Training 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 104.65, "gross_charge": 161.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000059", "type": "CDM" }, { "code": "430", "type": "RC" } ], "description": "Hc Ot Tx Cot 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13.65, "gross_charge": 21.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000060", "type": "CDM" }, { "code": "430", "type": "RC" } ], "description": "Hc Ot Eval Eov", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.9, "gross_charge": 166.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000063", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97755", "type": "HCPCS" } ], "description": "Hc Assist Tech Assess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 59.8, "gross_charge": 92.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000064", "type": "CDM" }, { "code": "430", "type": "RC" } ], "description": "Hc Ot Tx Ot Pt Assistant 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11.7, "gross_charge": 18.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000065", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "G0283", "type": "HCPCS" } ], "description": "Hc Ot Electrical Stim Unattended", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.05, "gross_charge": 197.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000066", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "W0637", "type": "HCPCS" } ], "description": "Hc Ot Bwc Transitional Work Per 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 66.95, "gross_charge": 103.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000067", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "W0710", "type": "HCPCS" } ], "description": "Hc Ot Bwc Work Conditioning Per 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000069", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97763", "type": "HCPCS" } ], "description": "Hc Ot Subsequent Orthotic Prosthetic Check 15Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 107.9, "gross_charge": 166.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000072", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "99366", "type": "HCPCS" } ], "description": "Hc Ot Rehab Family Conference - 30 Min Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000073", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "96112", "type": "HCPCS" } ], "description": "Hc Ot Developmental Testing, First Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 433.55, "gross_charge": 667.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000074", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "96113", "type": "HCPCS" } ], "description": "Hc Ot Developmental Testing, Ea Add 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 216.45, "gross_charge": 333.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000075", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97129", "type": "HCPCS" } ], "description": "Hc Ot Cognitive Training Initial 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000076", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97130", "type": "HCPCS" } ], "description": "Hc Ot Cognitive Training Each Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000078", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "W0645", "type": "HCPCS" } ], "description": "Hc Ot Job Analysis 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 93.6, "gross_charge": 144.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000079", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29581", "type": "HCPCS" } ], "description": "Hc Ot Applic Multi Layer Comp Sys Leg/Ankle/Foot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 609.7, "gross_charge": 938.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000079_50", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29581", "type": "HCPCS" } ], "description": "Hc Ot Applic Multi Layer Comp Sys Leg/Ankle/Foot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1219.4, "gross_charge": 1876.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "43000080", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29584", "type": "HCPCS" } ], "description": "Hc Ot Applic Multi Layer Comp Sys Arm/Hand/Fingers", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 731.9, "gross_charge": 1126.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000080_50", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "29584", "type": "HCPCS" } ], "description": "Hc Ot Applic Multi Layer Comp Sys Arm/Hand/Fingers", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1463.8, "gross_charge": 2252.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "43000081", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "G0281", "type": "HCPCS" } ], "description": "Hc Ot E-Stim Unattend For Chronic Ulcers", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.05, "gross_charge": 197.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000082", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "G0282", "type": "HCPCS" } ], "description": "Hc Ot E-Stim Unattend For Wound Care Other", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 128.05, "gross_charge": 197.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000083", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97550", "type": "HCPCS" } ], "description": "Hc Ot Caregiver Training Initial 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 228.8, "gross_charge": 352.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000084", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97551", "type": "HCPCS" } ], "description": "Hc Ot Caregiver Training Ea Add 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "43000085", "type": "CDM" }, { "code": "430", "type": "RC" }, { "code": "97552", "type": "HCPCS" } ], "description": "Hc Ot Caregiver Training Group", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.85, "gross_charge": 89.0, "setting": "both" } ] }, { "code_information": [ { "code": "43400006", "type": "CDM" }, { "code": "434", "type": "RC" }, { "code": "97165", "type": "HCPCS" } ], "description": "Hc Ot Eval Low Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 261.3, "gross_charge": 402.0, "setting": "both" } ] }, { "code_information": [ { "code": "43400007", "type": "CDM" }, { "code": "434", "type": "RC" }, { "code": "97166", "type": "HCPCS" } ], "description": "Hc Ot Eval Moderate Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 274.3, "gross_charge": 422.0, "setting": "both" } ] }, { "code_information": [ { "code": "43400008", "type": "CDM" }, { "code": "434", "type": "RC" }, { "code": "97167", "type": "HCPCS" } ], "description": "Hc Ot Eval High Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 288.6, "gross_charge": 444.0, "setting": "both" } ] }, { "code_information": [ { "code": "43400009", "type": "CDM" }, { "code": "434", "type": "RC" }, { "code": "97168", "type": "HCPCS" } ], "description": "Hc Ot Re-Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 169.65, "gross_charge": 261.0, "setting": "both" } ] }, { "code_information": [ { "code": "43400010", "type": "CDM" }, { "code": "434", "type": "RC" } ], "description": "Hc Ot Drive Low Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 176.8, "gross_charge": 272.0, "setting": "both" } ] }, { "code_information": [ { "code": "43400011", "type": "CDM" }, { "code": "434", "type": "RC" } ], "description": "Hc Ot Drive Moderate Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 176.8, "gross_charge": 272.0, "setting": "both" } ] }, { "code_information": [ { "code": "43400012", "type": "CDM" }, { "code": "434", "type": "RC" } ], "description": "Hc Ot Drive High Complexity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 176.8, "gross_charge": 272.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000002", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92507", "type": "HCPCS" } ], "description": "Hc St Ped Treat Basic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 218.4, "gross_charge": 336.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000003", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92507", "type": "HCPCS" } ], "description": "Hc St Ped Treat Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 270.4, "gross_charge": 416.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000004", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92507", "type": "HCPCS" } ], "description": "Hc St Treat Basic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 218.4, "gross_charge": 336.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000005", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92507", "type": "HCPCS" } ], "description": "Hc St Treat Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 270.4, "gross_charge": 416.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000007", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92508", "type": "HCPCS" } ], "description": "Hc St Therapy Group", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 101.4, "gross_charge": 156.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000009", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92526", "type": "HCPCS" } ], "description": "Hc Treat Swall Oral Function Basic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 196.95, "gross_charge": 303.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000010", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92526", "type": "HCPCS" } ], "description": "Hc Treat Swall Oral Func Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 252.85, "gross_charge": 389.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000036", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "96125", "type": "HCPCS" } ], "description": "Hc St Standard Cognitive Performance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 191.1, "gross_charge": 294.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000037", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "92609", "type": "HCPCS" } ], "description": "Hc Speech Gen Device Services", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 228.15, "gross_charge": 351.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000039", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97533", "type": "HCPCS" } ], "description": "Hc St Sensory Integration 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 104.65, "gross_charge": 161.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000041", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "99366", "type": "HCPCS" } ], "description": "Hc St Rehab Family Conference - 30 Min Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000042", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97537", "type": "HCPCS" } ], "description": "Hc St Community Work Reintegration 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.85, "gross_charge": 129.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000043", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97530", "type": "HCPCS" } ], "description": "Hc St Functional Activity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 123.5, "gross_charge": 190.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000044", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "96112", "type": "HCPCS" } ], "description": "Hc St Developmental Testing, First Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 433.55, "gross_charge": 667.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000045", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "96113", "type": "HCPCS" } ], "description": "Hc St Developmental Testing, Ea Add 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 216.45, "gross_charge": 333.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000046", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97129", "type": "HCPCS" } ], "description": "Hc St Cognitive Training Initial 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000047", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97130", "type": "HCPCS" } ], "description": "Hc St Cognitive Training Each Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 85.8, "gross_charge": 132.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000048", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "90912", "type": "HCPCS" } ], "description": "Hc Pt Biofeedback Training Perineal Anorectal Or Urethral Sphincter Initial 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 110.5, "gross_charge": 170.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000049", "type": "CDM" }, { "code": "420", "type": "RC" }, { "code": "90913", "type": "HCPCS" } ], "description": "Hc Pt Biofeedback Training Perineal Anorectal Or Urethral Sphincter Ea Addl 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 110.5, "gross_charge": 170.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000050", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97550", "type": "HCPCS" } ], "description": "Hc St Caregiver Training Initial 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 228.8, "gross_charge": 352.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000051", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97551", "type": "HCPCS" } ], "description": "Hc St Caregiver Training Ea Add 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "44000052", "type": "CDM" }, { "code": "440", "type": "RC" }, { "code": "97552", "type": "HCPCS" } ], "description": "Hc St Caregiver Training Group", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 57.85, "gross_charge": 89.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400003", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92597", "type": "HCPCS" } ], "description": "Hc St Eval Voice Prosthetic Basic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 88.4, "gross_charge": 136.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400004", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92597", "type": "HCPCS" } ], "description": "Hc St Eval Voice Prosthetic Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 169.65, "gross_charge": 261.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400005", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92607", "type": "HCPCS" } ], "description": "Hc St Eval Speech Device 1St Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 263.25, "gross_charge": 405.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400006", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92608", "type": "HCPCS" } ], "description": "Hc St Eval Speech Device Ea Addl 30M", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400007", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92610", "type": "HCPCS" } ], "description": "Hc Eval Swallow Oral Func Basic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 190.45, "gross_charge": 293.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400008", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92610", "type": "HCPCS" } ], "description": "Hc Eval Swallow Oral Func Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 282.75, "gross_charge": 435.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400009", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92610", "type": "HCPCS" } ], "description": "Hc Ped Eval Swall/Oral Func Basic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 190.45, "gross_charge": 293.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400010", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92611", "type": "HCPCS" } ], "description": "Hc St Eval Swall Video/Fluoro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 299.0, "gross_charge": 460.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400011", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92612", "type": "HCPCS" } ], "description": "Hc St Eval Swall Endo Cine/Video", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 345.8, "gross_charge": 532.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400012", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "96105", "type": "HCPCS" } ], "description": "Hc St Eval Aphasia Per Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 318.5, "gross_charge": 490.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400014", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92521", "type": "HCPCS" } ], "description": "Hc St Speech Fluency Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.25, "gross_charge": 205.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400015", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92522", "type": "HCPCS" } ], "description": "Hc St Speech Sound Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 109.2, "gross_charge": 168.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400016", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92523", "type": "HCPCS" } ], "description": "Hc St Speech And Comprehension Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 226.85, "gross_charge": 349.0, "setting": "both" } ] }, { "code_information": [ { "code": "44400017", "type": "CDM" }, { "code": "444", "type": "RC" }, { "code": "92524", "type": "HCPCS" } ], "description": "Hc St Behvrl And Qual Analysis Of Voice", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000001", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "29130", "type": "HCPCS" } ], "description": "Hc Application Finger Splint", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 448.5, "gross_charge": 690.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000001_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "29130", "type": "HCPCS" } ], "description": "Hc Application Finger Splint", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 897.0, "gross_charge": 1380.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000002", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30300", "type": "HCPCS" } ], "description": "Hc Removal Foreign Body Nasal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 445.25, "gross_charge": 685.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000003", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30901", "type": "HCPCS" } ], "description": "Hc Control Nosebleed Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 835.25, "gross_charge": 1285.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000003_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30901", "type": "HCPCS" } ], "description": "Hc Control Nosebleed Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1670.5, "gross_charge": 2570.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000004", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30903", "type": "HCPCS" } ], "description": "Hc Control Nosebleed Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1210.3, "gross_charge": 1862.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000004_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30903", "type": "HCPCS" } ], "description": "Hc Control Nosebleed Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2420.6, "gross_charge": 3724.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000005", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "31500", "type": "HCPCS" } ], "description": "Hc Intubation Endotracheal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1277.9, "gross_charge": 1966.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000006", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "31605", "type": "HCPCS" } ], "description": "Hc Tracheotomy Cricothyroidotomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2701.4, "gross_charge": 4156.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000007", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "36680", "type": "HCPCS" } ], "description": "Hc Needle Plcmt Intraosseous Infusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 747.5, "gross_charge": 1150.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000008", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "40650", "type": "HCPCS" } ], "description": "Hc Repair Lip Vermilion Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 830.05, "gross_charge": 1277.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000009", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "40800", "type": "HCPCS" } ], "description": "Hc Drn Abs/Cyst/Hemtma/Mouth Smpl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 581.75, "gross_charge": 895.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000010", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "41800", "type": "HCPCS" } ], "description": "Hc Drain Dental Abscess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 885.3, "gross_charge": 1362.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000011", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "42700", "type": "HCPCS" } ], "description": "Hc I And D Peritonsillar Abscess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 926.9, "gross_charge": 1426.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000012", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "43753", "type": "HCPCS" } ], "description": "Hc Gastric Intub And Aspiration", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 793.0, "gross_charge": 1220.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000014", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "46050", "type": "HCPCS" } ], "description": "Hc I And D Perianal Abscess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 901.55, "gross_charge": 1387.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000015", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "46083", "type": "HCPCS" } ], "description": "Hc Incision External Hemorrhoid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 877.5, "gross_charge": 1350.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000016", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "46600", "type": "HCPCS" } ], "description": "Hc Anoscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 306.8, "gross_charge": 472.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000017", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "49084", "type": "HCPCS" } ], "description": "Hc Peritoneal Lavage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1472.9, "gross_charge": 2266.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000018", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "56405", "type": "HCPCS" } ], "description": "Hc I And D Vulva Or Perineal Abscess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1211.6, "gross_charge": 1864.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000019", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "56420", "type": "HCPCS" } ], "description": "Hc I And D Bartholin's Gland Abscess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 885.3, "gross_charge": 1362.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000021", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "65205", "type": "HCPCS" } ], "description": "Hc Remove Fb External Eye", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 449.15, "gross_charge": 691.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000021_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "65205", "type": "HCPCS" } ], "description": "Hc Remove Fb External Eye", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 898.3, "gross_charge": 1382.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000022", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "65222", "type": "HCPCS" } ], "description": "Hc Remove Fb Cornea W Slit Lamp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 490.1, "gross_charge": 754.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000022_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "65222", "type": "HCPCS" } ], "description": "Hc Remove Fb Cornea W Slit Lamp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 980.2, "gross_charge": 1508.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000023", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69000", "type": "HCPCS" } ], "description": "Hc Drain Abscess Or Hematoma Ext Ear Smpl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 597.35, "gross_charge": 919.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000023_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69000", "type": "HCPCS" } ], "description": "Hc Drain Abscess Or Hematoma Ext Ear Smpl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1194.7, "gross_charge": 1838.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000024", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69200", "type": "HCPCS" } ], "description": "Hc Remove Foreign Body Ear", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 445.25, "gross_charge": 685.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000024_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69200", "type": "HCPCS" } ], "description": "Hc Remove Foreign Body Ear", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 890.5, "gross_charge": 1370.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000025", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69210", "type": "HCPCS" } ], "description": "Hc Removal Impacted Cerumen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 630.5, "gross_charge": 970.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000025_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69210", "type": "HCPCS" } ], "description": "Hc Removal Impacted Cerumen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1261.0, "gross_charge": 1940.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000026", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "92950", "type": "HCPCS" } ], "description": "Hc Cpr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1597.7, "gross_charge": 2458.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000027", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "92953", "type": "HCPCS" } ], "description": "Hc Temporary External Pacing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 895.7, "gross_charge": 1378.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000028", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92960", "type": "HCPCS" } ], "description": "Hc Cardioversion Elective External", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5136.3, "gross_charge": 7902.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000029", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "97602", "type": "HCPCS" } ], "description": "Hc Debrid Nonselect Wet Moist Dressing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 810.55, "gross_charge": 1247.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000030", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "99281", "type": "HCPCS" } ], "description": "Hc Er Level I", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 437.45, "gross_charge": 673.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000032", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "99282", "type": "HCPCS" } ], "description": "Hc Er Level Ii", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 717.6, "gross_charge": 1104.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000034", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "99283", "type": "HCPCS" } ], "description": "Hc Er Level Iii", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1136.2, "gross_charge": 1748.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000036", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "99284", "type": "HCPCS" } ], "description": "Hc Er Level Iv", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1879.15, "gross_charge": 2891.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000038", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "99285", "type": "HCPCS" } ], "description": "Hc Er Level V", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2693.6, "gross_charge": 4144.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000040", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "99291", "type": "HCPCS" } ], "description": "Hc Critical Care First 30 To 74 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3766.1, "gross_charge": 5794.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000041", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "99292", "type": "HCPCS" } ], "description": "Hc Er Critical Care Addl 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 461.5, "gross_charge": 710.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000042", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Apply Casts Body And Upper Ext", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1002.95, "gross_charge": 1543.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000043", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Apply Casts Lower Ext", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1036.75, "gross_charge": 1595.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000044", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Apply Splints Body And Upper Ext", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 677.3, "gross_charge": 1042.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000045", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Apply Splints Lower Ext", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 472.55, "gross_charge": 727.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000046", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Rep Window Wedge Cast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 512.85, "gross_charge": 789.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000047", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Thoracotomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4694.3, "gross_charge": 7222.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000048", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Tx Fx Dislocation Open", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 920.4, "gross_charge": 1416.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000049", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Tx Fx Dislocation W Anesthesia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1254.5, "gross_charge": 1930.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000050", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Tx Fx Dislocation Wo Anesthesia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 634.4, "gross_charge": 976.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000051", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "11719", "type": "HCPCS" } ], "description": "Hc Trim Of Nondystrophic Nails", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 121.55, "gross_charge": 187.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000058", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "20525", "type": "HCPCS" } ], "description": "Hc Rem Fb Muscle Or Tendon Sheath Complex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3311.1, "gross_charge": 5094.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000140", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "26010", "type": "HCPCS" } ], "description": "Hc Drain Finger Abcess Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1137.5, "gross_charge": 1750.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000173", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29280", "type": "HCPCS" } ], "description": "Hc Strapping Hand Or Finger", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 770.9, "gross_charge": 1186.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000173_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29280", "type": "HCPCS" } ], "description": "Hc Strapping Hand Or Finger", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1541.8, "gross_charge": 2372.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000177", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29445", "type": "HCPCS" } ], "description": "Hc Appl Rigid Total Cont Leg Cast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1384.5, "gross_charge": 2130.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000177_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29445", "type": "HCPCS" } ], "description": "Hc Appl Rigid Total Cont Leg Cast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2769.0, "gross_charge": 4260.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000183", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29550", "type": "HCPCS" } ], "description": "Hc Strapping Toe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 770.9, "gross_charge": 1186.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000183_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29550", "type": "HCPCS" } ], "description": "Hc Strapping Toe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1541.8, "gross_charge": 2372.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000191", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "31505", "type": "HCPCS" } ], "description": "Hc Laryngscpy Indirect Diagnos", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 536.25, "gross_charge": 825.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000213", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "42960", "type": "HCPCS" } ], "description": "Hc Control Oropharyngeal Hemor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 830.05, "gross_charge": 1277.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000215", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "44799", "type": "HCPCS" } ], "description": "Hc Unlist Procedure Intestine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1236.95, "gross_charge": 1903.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000217", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "46040", "type": "HCPCS" } ], "description": "Hc I&D Ischrec Perirec Abcess", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2080.0, "gross_charge": 3200.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000218", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "46320", "type": "HCPCS" } ], "description": "Hc Enuc Excsn Ext Thrm Hemorrd", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3578.9, "gross_charge": 5506.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000219", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "46999", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Anus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3140.8, "gross_charge": 4832.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000225", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "54220", "type": "HCPCS" } ], "description": "Hc Irrigation Of Corpona Cavernos", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 967.85, "gross_charge": 1489.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000228", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "55899", "type": "HCPCS" } ], "description": "Hc Unlst Proc Male Genital Sys", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 967.85, "gross_charge": 1489.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000233", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "65220", "type": "HCPCS" } ], "description": "Hc Rem Fb Ext Eye Corn Wo Lmp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 490.1, "gross_charge": 754.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000233_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "65220", "type": "HCPCS" } ], "description": "Hc Rem Fb Ext Eye Corn Wo Lmp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 980.2, "gross_charge": 1508.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000243", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "98926", "type": "HCPCS" } ], "description": "Hc Osteo Manip Tx 3-4 Body Region", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 390.0, "gross_charge": 600.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000248", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "51703", "type": "HCPCS" } ], "description": "Hc Insertion Catheter Complicated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 881.4, "gross_charge": 1356.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000250", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69209", "type": "HCPCS" } ], "description": "Hc Removal Impacted Cerumen By Irrig Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 584.35, "gross_charge": 899.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000250_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "69209", "type": "HCPCS" } ], "description": "Hc Removal Impacted Cerumen By Irrig Unilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1168.7, "gross_charge": 1798.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000251", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "67700", "type": "HCPCS" } ], "description": "Hc Blepharotomy For Abscess Drainage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1231.1, "gross_charge": 1894.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000252", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "54235", "type": "HCPCS" } ], "description": "Hc Injection Of Corpora Cavernosa With Pharm Agent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 967.85, "gross_charge": 1489.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000253", "type": "CDM" }, { "code": "450", "type": "RC" } ], "description": "Hc Strapping Upper Extremity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 543.4, "gross_charge": 836.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000254", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "26011", "type": "HCPCS" } ], "description": "Hc Drainage Of Finger Abscess Complicated", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2596.75, "gross_charge": 3995.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000255", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30906", "type": "HCPCS" } ], "description": "Hc Cntrl Post Nosebleed Subqnt Uni Or Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1413.1, "gross_charge": 2174.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000256", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30905", "type": "HCPCS" } ], "description": "Hc Cntrl Post Nosebleed Init", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 906.1, "gross_charge": 1394.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000256_50", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "30905", "type": "HCPCS" } ], "description": "Hc Cntrl Post Nosebleed Init", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1812.2, "gross_charge": 2788.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "45000257", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "33025", "type": "HCPCS" } ], "description": "Hc Creation Of Pericardiotomy Window", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4087.2, "gross_charge": 6288.0, "setting": "both" } ] }, { "code_information": [ { "code": "45000258", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "19020", "type": "HCPCS" } ], "description": "Hc Incision Of Breast Lesion W Exploration Or Drainage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3777.8, "gross_charge": 5812.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000001", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94010", "type": "HCPCS" } ], "description": "Hc Spirometry Pft Simple", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 439.4, "gross_charge": 676.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000002", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94060", "type": "HCPCS" } ], "description": "Hc Spirometry Pft Pre Post Bronchodilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 887.9, "gross_charge": 1366.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000003", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94070", "type": "HCPCS" } ], "description": "Hc Spirometry Bronchial Provocation Challenge", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1708.2, "gross_charge": 2628.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000004", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94452", "type": "HCPCS" } ], "description": "Hc High Altitude Sim Test", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 406.25, "gross_charge": 625.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000005", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94453", "type": "HCPCS" } ], "description": "Hc High Altitude Sim Test W O2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 406.25, "gross_charge": 625.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000008", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94621", "type": "HCPCS" } ], "description": "Hc Cardiopulmonary Exercise Testing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1992.9, "gross_charge": 3066.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000010", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94726", "type": "HCPCS" } ], "description": "Hc Lung Vols Plethysmography W Wo Airway Resistance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 122.2, "gross_charge": 188.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000011", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94727", "type": "HCPCS" } ], "description": "Hc Lung Vols Washout Gas Dilution", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 276.9, "gross_charge": 426.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000012", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94729", "type": "HCPCS" } ], "description": "Hc Carbon Monoxide Diff Dlco", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 282.75, "gross_charge": 435.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000013", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94762", "type": "HCPCS" } ], "description": "Hc Pulse Ox Overnight Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 266.5, "gross_charge": 410.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000020", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94617", "type": "HCPCS" } ], "description": "Hc Exer Test For Brnchspasm W Pre Post Spiro Ecg Record And Pulse Ox", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 401.7, "gross_charge": 618.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000021", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94618", "type": "HCPCS" } ], "description": "Hc Pulm Stress Test Heart Rate Oxmtry And Oxygen Titration When Perf", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 401.7, "gross_charge": 618.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000022", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94780", "type": "HCPCS" } ], "description": "Hc Car Seat Testing 1St 60 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 91.65, "gross_charge": 141.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000023", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94781", "type": "HCPCS" } ], "description": "Hc Car Seat Testing Each Addl Full 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 34.45, "gross_charge": 53.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000026", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94619", "type": "HCPCS" } ], "description": "Hc Pulm Stress Test Heart Rate Oxmtry Oxygen Titration Wo Ecg Record", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 401.7, "gross_charge": 618.0, "setting": "both" } ] }, { "code_information": [ { "code": "46000027", "type": "CDM" }, { "code": "460", "type": "RC" }, { "code": "94690", "type": "HCPCS" } ], "description": "Hc O2 Uptake Exp Gas Analysis Rest Indirect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 195.0, "gross_charge": 300.0, "setting": "both" } ] }, { "code_information": [ { "code": "47100002", "type": "CDM" }, { "code": "471", "type": "RC" }, { "code": "92551", "type": "HCPCS" } ], "description": "Hc Audio Pure Tone Air Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 71.5, "gross_charge": 110.0, "setting": "both" } ] }, { "code_information": [ { "code": "47100006", "type": "CDM" }, { "code": "471", "type": "RC" }, { "code": "92587", "type": "HCPCS" } ], "description": "Hc Auditory Evoked Oae", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 164.45, "gross_charge": 253.0, "setting": "both" } ] }, { "code_information": [ { "code": "47100007", "type": "CDM" }, { "code": "471", "type": "RC" }, { "code": "92558", "type": "HCPCS" } ], "description": "Hc Hearing Screen Evoked Oae", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 71.5, "gross_charge": 110.0, "setting": "both" } ] }, { "code_information": [ { "code": "47100008", "type": "CDM" }, { "code": "471", "type": "RC" }, { "code": "92552", "type": "HCPCS" } ], "description": "Hc Audiometry Pure Tone, Air Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 71.5, "gross_charge": 110.0, "setting": "both" } ] }, { "code_information": [ { "code": "47100009", "type": "CDM" }, { "code": "471", "type": "RC" }, { "code": "92553", "type": "HCPCS" } ], "description": "Hc Audiometry Pure Tone, Air And Bone", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 86.45, "gross_charge": 133.0, "setting": "both" } ] }, { "code_information": [ { "code": "47100013", "type": "CDM" }, { "code": "471", "type": "RC" }, { "code": "92650", "type": "HCPCS" } ], "description": "Hc Auditory Ep Screen Auditory Potential W Broadband Stimuli Analysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 52.65, "gross_charge": 81.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000001", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92973", "type": "HCPCS" } ], "description": "Hc Perc Translumin Cor Thrombectomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2616.9, "gross_charge": 4026.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000004", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92978", "type": "HCPCS" } ], "description": "Hc Ivus Coronary Initial Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3599.7, "gross_charge": 5538.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000005", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92979", "type": "HCPCS" } ], "description": "Hc Ivus Coronary Each Addl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1833.0, "gross_charge": 2820.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000007", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93279", "type": "HCPCS" } ], "description": "Hc Program Device Eval Single Pacer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.25, "gross_charge": 205.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000008", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93280", "type": "HCPCS" } ], "description": "Hc Program Device Eval Dual Pacer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.25, "gross_charge": 205.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000009", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93281", "type": "HCPCS" } ], "description": "Hc Program Device Eval Multi Pacer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 154.7, "gross_charge": 238.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000010", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93282", "type": "HCPCS" } ], "description": "Hc Program Device Eval Single Defib", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 143.0, "gross_charge": 220.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000011", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93283", "type": "HCPCS" } ], "description": "Hc Program Device Eval Dual Defib", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 181.35, "gross_charge": 279.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000012", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93284", "type": "HCPCS" } ], "description": "Hc Program Device Eval Multi Defib", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 205.4, "gross_charge": 316.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000013", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93285", "type": "HCPCS" } ], "description": "Hc Program Sq Crm Incl Retreival Report", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 94.25, "gross_charge": 145.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000014", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93288", "type": "HCPCS" } ], "description": "Hc Interrogation Pacer Wo Reprogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000015", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93289", "type": "HCPCS" } ], "description": "Hc Interrogation Defib Wo Reprogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.0, "gross_charge": 200.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000016", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93290", "type": "HCPCS" } ], "description": "Hc Interrogation Implant Monitor System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 60.45, "gross_charge": 93.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000017", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93291", "type": "HCPCS" } ], "description": "Hc Interrogation Sq Crm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 72.8, "gross_charge": 112.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000018", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93293", "type": "HCPCS" } ], "description": "Hc Transtelephonic Pacer Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000019", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93296", "type": "HCPCS" } ], "description": "Hc Interrogation Pacer Defib Remote", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 63.05, "gross_charge": 97.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000020", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "G2066", "type": "HCPCS" } ], "description": "Hc Remote Interrogation Sq Crm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 108.55, "gross_charge": 167.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000021", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93572", "type": "HCPCS" } ], "description": "Hc Heart Flow Reserve Measure Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1866.8, "gross_charge": 2872.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000022", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93580", "type": "HCPCS" } ], "description": "Hc Transcath Closure Asd W/Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10746.45, "gross_charge": 16533.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000023", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93581", "type": "HCPCS" } ], "description": "Hc Transcath Closure Vsd W/Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11596.65, "gross_charge": 17841.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000024", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93600", "type": "HCPCS" } ], "description": "Hc Bundle Of His Recording", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4498.65, "gross_charge": 6921.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000025", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93602", "type": "HCPCS" } ], "description": "Hc Intra Atrial Recording", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4046.25, "gross_charge": 6225.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000026", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93603", "type": "HCPCS" } ], "description": "Hc Right Ventricular Recording", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4717.05, "gross_charge": 7257.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000027", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93609", "type": "HCPCS" } ], "description": "Hc Intravent Intra Atrial Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8645.0, "gross_charge": 13300.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000028", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93610", "type": "HCPCS" } ], "description": "Hc Intra Atrial Pacing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4091.1, "gross_charge": 6294.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000029", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93612", "type": "HCPCS" } ], "description": "Hc Intraventricular Pacing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4717.05, "gross_charge": 7257.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000030", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93613", "type": "HCPCS" } ], "description": "Hc Intracard Electrophys 3D Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9948.9, "gross_charge": 15306.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000031", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93618", "type": "HCPCS" } ], "description": "Hc Arrhythmia Induction Electrical", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4156.75, "gross_charge": 6395.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000032", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93619", "type": "HCPCS" } ], "description": "Hc Ep Comprehensive Wo Induction Arrhythmia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10442.9, "gross_charge": 16066.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000033", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93620", "type": "HCPCS" } ], "description": "Hc Ep Comprehensive W Induction Arrhythmia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20671.3, "gross_charge": 31802.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000034", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93621", "type": "HCPCS" } ], "description": "Hc Ep Comprehensive Left Atrium", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8763.3, "gross_charge": 13482.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000035", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93622", "type": "HCPCS" } ], "description": "Hc Ep Comprehensive Left Ventricle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8824.4, "gross_charge": 13576.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000036", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93623", "type": "HCPCS" } ], "description": "Hc Ep Study With Rx", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5504.85, "gross_charge": 8469.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000037", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93624", "type": "HCPCS" } ], "description": "Hc Ep Followup Study", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12804.35, "gross_charge": 19699.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000038", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93640", "type": "HCPCS" } ], "description": "Hc Analysis Icd Leads At Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3353.35, "gross_charge": 5159.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000039", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93641", "type": "HCPCS" } ], "description": "Hc Analysis Icd Lead Generator At Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2817.1, "gross_charge": 4334.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000040", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93642", "type": "HCPCS" } ], "description": "Hc Ep Eval Icd Implant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7577.05, "gross_charge": 11657.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000041", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93650", "type": "HCPCS" } ], "description": "Hc Ablation Av", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17100.85, "gross_charge": 26309.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000042", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93653", "type": "HCPCS" } ], "description": "Hc Ep Eval W Ablation Svt Including 3D Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 41078.7, "gross_charge": 63198.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000043", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93654", "type": "HCPCS" } ], "description": "Hc Ep Eval W Ablation Vt Including 3D Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 41078.7, "gross_charge": 63198.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000044", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93655", "type": "HCPCS" } ], "description": "Hc Ablation Distinct From Primary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4202.9, "gross_charge": 6466.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000045", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93656", "type": "HCPCS" } ], "description": "Hc Ep Eval W Ablation A Fib Including 3D Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 41078.7, "gross_charge": 63198.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000046", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93657", "type": "HCPCS" } ], "description": "Hc Ablation Addl A Fib", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4202.9, "gross_charge": 6466.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000047", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93660", "type": "HCPCS" } ], "description": "Hc Tilt Table Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1955.2, "gross_charge": 3008.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000048", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93662", "type": "HCPCS" } ], "description": "Hc Intracardiac Echo Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3429.4, "gross_charge": 5276.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000050", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93750", "type": "HCPCS" } ], "description": "Hc Interrogation Vad", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 255.45, "gross_charge": 393.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000052", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93799", "type": "HCPCS" } ], "description": "Hc Unlisted Cardiovascular Procedure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2948.4, "gross_charge": 4536.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000053", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "G0166", "type": "HCPCS" } ], "description": "Hc External Counterpulsation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4488.9, "gross_charge": 6906.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000056", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93583", "type": "HCPCS" } ], "description": "Hc Perq Transcath Septal Reduction", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10746.45, "gross_charge": 16533.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000058", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93261", "type": "HCPCS" } ], "description": "Hc Subq Defib Interrogation Device Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 160.55, "gross_charge": 247.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000059", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93260", "type": "HCPCS" } ], "description": "Hc Subq Defib Programming Device Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 158.6, "gross_charge": 244.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000060", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93260", "type": "HCPCS" } ], "description": "Hc Implant Subq Defib Device Sys Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 158.6, "gross_charge": 244.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000062", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93644", "type": "HCPCS" } ], "description": "Hc Ep Eval Subq Implantable Defib", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 143.0, "gross_charge": 220.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000063", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93571", "type": "HCPCS" } ], "description": "Hc Heart Flow Reserve Measure Init", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3415.75, "gross_charge": 5255.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000064", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93590", "type": "HCPCS" } ], "description": "Hc Perc Transcath Closure Paravalvular Leak Mitral Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10746.45, "gross_charge": 16533.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000065", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93591", "type": "HCPCS" } ], "description": "Hc Perc Transcath Closure Paravalvular Leak Aortic Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10746.45, "gross_charge": 16533.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000066", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93592", "type": "HCPCS" } ], "description": "Hc Perc Transcath Closure Paravalvular Leak Each Addl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5191.55, "gross_charge": 7987.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000070", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93286", "type": "HCPCS" } ], "description": "Hc Peri-Proc Device Eval And Program Pacemaker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 139.1, "gross_charge": 214.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000071", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93287", "type": "HCPCS" } ], "description": "Hc Peri-Proc Device Eval And Program Implantable Defibrillator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 184.6, "gross_charge": 284.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000072", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93668", "type": "HCPCS" } ], "description": "Hc Peripheral Arterial Diseas (Pad) Rehabilitation, Per Session", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.05, "gross_charge": 177.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000075", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0575T", "type": "HCPCS" } ], "description": "Hc Prog Device Eval In Person Implnt Cardioverter Deb System W Adjustment", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 158.6, "gross_charge": 244.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000077", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0577T", "type": "HCPCS" } ], "description": "Hc Prog Device Eval In Person Implnt Cardioverter Deb System W Arrythmia Induct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 690.95, "gross_charge": 1063.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000079", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0579T", "type": "HCPCS" } ], "description": "Hc Interrog Device Eval Remote Up To 90 Days Cardio Defib W Remote Data Acq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.3, "gross_charge": 222.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000080", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93724", "type": "HCPCS" } ], "description": "Hc Electronic Analysis Antitachycardia Pacemaker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 791.7, "gross_charge": 1218.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000083", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92998", "type": "HCPCS" } ], "description": "Hc Perct Balloon Angioplasty Pulmnary Ea Addtl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5183.75, "gross_charge": 7975.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000084", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93615", "type": "HCPCS" } ], "description": "Hc Esophageal Rec Atrial Electrogram", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4717.05, "gross_charge": 7257.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000085", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93616", "type": "HCPCS" } ], "description": "Hc Esophageal Rec Atrial Electrogram W Pacing", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4717.05, "gross_charge": 7257.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000086", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93631", "type": "HCPCS" } ], "description": "Hc Intraop Epi And Endocardial Pacing Localize Tachycardia", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 289.25, "gross_charge": 445.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000087", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "33269", "type": "HCPCS" } ], "description": "Hc Exclusion L Atr Appendage Thoracoscopic Any Method", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000094", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0680T", "type": "HCPCS" } ], "description": "Hc Ins Rplcmt Pulse Generator Only Isdss", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2366.0, "gross_charge": 3640.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000095", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0681T", "type": "HCPCS" } ], "description": "Hc Relocation Pulse Generator Only Isdss", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1993.55, "gross_charge": 3067.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000096", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0682T", "type": "HCPCS" } ], "description": "Hc Removal Pulse Generator Only Isdss", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15401.75, "gross_charge": 23695.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000097", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0695T", "type": "HCPCS" } ], "description": "Hc Bdy Surf Activation Mapg Pm Cvdfb Leads Tm Implt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 158.6, "gross_charge": 244.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000098", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0696T", "type": "HCPCS" } ], "description": "Hc Bdy Surf Activation Mapg Pm Cvdfb Leads Tm Flwup", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 158.6, "gross_charge": 244.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000099", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93786", "type": "HCPCS" } ], "description": "Hc Ambulatory Bp Monitor 24Hr Or More - Recording Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 337.35, "gross_charge": 519.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000100", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0745T", "type": "HCPCS" } ], "description": "Hc Cardiac Ablation Radiation Non-Invasive Arrhythmia Local", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7231.9, "gross_charge": 11126.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000101", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0746T", "type": "HCPCS" } ], "description": "Hc Cardiac Ablation Radiation Conversion Arrhythmia Local Map", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7231.9, "gross_charge": 11126.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000102", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0747T", "type": "HCPCS" } ], "description": "Hc Cardiac Ablation Radiation Arrhythmia Deliv Rad Therapy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7231.9, "gross_charge": 11126.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000104", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "0826T", "type": "HCPCS" } ], "description": "Hc Eval Leadless Pacemaker W Adjust", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 133.25, "gross_charge": 205.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000105", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92972", "type": "HCPCS" } ], "description": "Hc Perc Transluminal Coronary Lithotripsy Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3900.0, "gross_charge": 6000.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000106", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "75580", "type": "HCPCS" } ], "description": "Hc Coronary Ffr Estimate From Ccta", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2446.6, "gross_charge": 3764.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000108", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93297", "type": "HCPCS" } ], "description": "Hc Remote Interrogation Cv Physiologic Ms - Heartlogic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 87.75, "gross_charge": 135.0, "setting": "both" } ] }, { "code_information": [ { "code": "48000109", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "93298", "type": "HCPCS" } ], "description": "Hc Remote Interrogation Of Sq Cardiac Rhythm Monitor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 97.5, "gross_charge": 150.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100001", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92920", "type": "HCPCS" } ], "description": "Hc Ptca Sgl Maj Cor Art Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4704.05, "gross_charge": 7237.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100002", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92921", "type": "HCPCS" } ], "description": "Hc Ptca Addl Branch Maj Cor Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4501.9, "gross_charge": 6926.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100003", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92924", "type": "HCPCS" } ], "description": "Hc Atherectomy Sgl Maj Cor Art Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11746.8, "gross_charge": 18072.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100004", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92925", "type": "HCPCS" } ], "description": "Hc Atherectomy Ea Add Branch Maj Cor Art", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10259.6, "gross_charge": 15784.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100005", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92928", "type": "HCPCS" } ], "description": "Hc Stent Sgl Maj Cor Art Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10559.25, "gross_charge": 16245.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100006", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92929", "type": "HCPCS" } ], "description": "Hc Stent Ea Addl Maj Cor Art Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9180.6, "gross_charge": 14124.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100007", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92933", "type": "HCPCS" } ], "description": "Hc Atherectomy W Stent Maj Cor Art Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11746.8, "gross_charge": 18072.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100008", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92937", "type": "HCPCS" } ], "description": "Hc Revascularization Cabg 1 Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10468.9, "gross_charge": 16106.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100009", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92938", "type": "HCPCS" } ], "description": "Hc Revascularization Cabg Ea Addl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9180.6, "gross_charge": 14124.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100010", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92941", "type": "HCPCS" } ], "description": "Hc Revasc Acute Occlusion During Mi Sgl Ves", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12540.45, "gross_charge": 19293.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100011", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92943", "type": "HCPCS" } ], "description": "Hc Revasc Chronic Occlusion Sgl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17406.35, "gross_charge": 26779.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100012", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92944", "type": "HCPCS" } ], "description": "Hc Revasc Chronic Occlusion Ea Addl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9180.6, "gross_charge": 14124.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100013", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92986", "type": "HCPCS" } ], "description": "Hc Percutaneous Balloon Valvoplasty Aortic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20675.85, "gross_charge": 31809.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100014", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92987", "type": "HCPCS" } ], "description": "Hc Percutaneous Balloon Valvoplasty Mitral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10367.5, "gross_charge": 15950.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100015", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92990", "type": "HCPCS" } ], "description": "Hc Percutaneous Balloon Valvoplasty Pulm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10367.5, "gross_charge": 15950.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100016", "type": "CDM" }, { "code": "480", "type": "RC" }, { "code": "92997", "type": "HCPCS" } ], "description": "Hc Percutaneous Balloon Angioplasty Pulmnary", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10367.5, "gross_charge": 15950.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100017", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93451", "type": "HCPCS" } ], "description": "Hc Right Heart Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8250.45, "gross_charge": 12693.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100018", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93452", "type": "HCPCS" } ], "description": "Hc Left Heart Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5912.4, "gross_charge": 9096.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100019", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93453", "type": "HCPCS" } ], "description": "Hc Right And Left Heart Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13904.15, "gross_charge": 21391.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100020", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93454", "type": "HCPCS" } ], "description": "Hc Coronary Angiography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7586.15, "gross_charge": 11671.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100021", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93455", "type": "HCPCS" } ], "description": "Hc Coronary Angio W Bypass Grafts", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9229.35, "gross_charge": 14199.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100022", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93456", "type": "HCPCS" } ], "description": "Hc Coronary Angiography W Rhc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10201.75, "gross_charge": 15695.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100023", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93457", "type": "HCPCS" } ], "description": "Hc Coronary Angiogrphy W Byp Grfts And Rhc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10389.6, "gross_charge": 15984.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100024", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93458", "type": "HCPCS" } ], "description": "Hc Coronary Angiography W Lhc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9351.55, "gross_charge": 14387.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100025", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93459", "type": "HCPCS" } ], "description": "Hc Coronary Angiogrphy W Byp Grfts And Lhc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9895.6, "gross_charge": 15224.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100026", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93460", "type": "HCPCS" } ], "description": "Hc Coronary Angiography W Lhc And Rhc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10295.35, "gross_charge": 15839.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100027", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93461", "type": "HCPCS" } ], "description": "Hc Coronary Angiogrphy W Byp Grfts Lhc And Rhc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11558.3, "gross_charge": 17782.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100028", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93462", "type": "HCPCS" } ], "description": "Hc Lhc Via Transseptal Puncture", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6917.95, "gross_charge": 10643.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100029", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93463", "type": "HCPCS" } ], "description": "Hc Pharm Agent Admin Nitric Oxide", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 789.1, "gross_charge": 1214.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100030", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93503", "type": "HCPCS" } ], "description": "Hc Insert Swan Ganz Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4790.5, "gross_charge": 7370.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100031", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93505", "type": "HCPCS" } ], "description": "Hc Biopsy Endomyocardial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7976.15, "gross_charge": 12271.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100032", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93566", "type": "HCPCS" } ], "description": "Hc Inj Right Atrial Ventricular Angio", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 789.1, "gross_charge": 1214.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100033", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93567", "type": "HCPCS" } ], "description": "Hc Inj Aortography Supravalvular", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2117.7, "gross_charge": 3258.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100034", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93568", "type": "HCPCS" } ], "description": "Hc Inj Pulmonary Angiography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2315.95, "gross_charge": 3563.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100035", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9600", "type": "HCPCS" } ], "description": "Hc De Stent Sgl Maj Cor Artery Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10559.25, "gross_charge": 16245.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100036", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9601", "type": "HCPCS" } ], "description": "Hc De Stent Ea Addl Maj Cor Artery Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4700.15, "gross_charge": 7231.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100037", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9602", "type": "HCPCS" } ], "description": "Hc De Stent W Ather Maj Cor Artery Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12982.45, "gross_charge": 19973.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100038", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9603", "type": "HCPCS" } ], "description": "Hc De Stent W Atherectomyaddl Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10259.6, "gross_charge": 15784.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100039", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9604", "type": "HCPCS" } ], "description": "Hc Revasc Cabg De Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11185.85, "gross_charge": 17209.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100040", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9605", "type": "HCPCS" } ], "description": "Hc Revasc De Stent Add Brnch Cabg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4805.45, "gross_charge": 7393.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100041", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9606", "type": "HCPCS" } ], "description": "Hc Revasc Occ During Mi De Stent Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13454.35, "gross_charge": 20699.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100042", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9607", "type": "HCPCS" } ], "description": "Hc Revasc Chronic Occ De Stent Sgl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17221.75, "gross_charge": 26495.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100043", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "C9608", "type": "HCPCS" } ], "description": "Hc Revasc Chronic Occ De Stent Addl Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7319.65, "gross_charge": 11261.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100045", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "92934", "type": "HCPCS" } ], "description": "Hc Atherectomy W Stent Addl Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 9180.6, "gross_charge": 14124.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100046", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33418", "type": "HCPCS" } ], "description": "Hc Transcath Mitral Valve Rep Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100047", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33419", "type": "HCPCS" } ], "description": "Hc Transcath Mitral Valve Rep Ea Add", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 848.25, "gross_charge": 1305.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100049", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33340", "type": "HCPCS" } ], "description": "Hc Transcatheter Closure L Atrial Appendage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100050", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0408T", "type": "HCPCS" } ], "description": "Hc Ins Or Rep Perm Card Contrac Mod Sys Pulse Gen W Transven Electrode", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 15613.0, "gross_charge": 24020.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100076", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0483T", "type": "HCPCS" } ], "description": "Hc Tmvi W Prosthetic Valve Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100077", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0484T", "type": "HCPCS" } ], "description": "Hc Tmvi W Prosthetic Valve Transthoracic Exposure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100078", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93464", "type": "HCPCS" } ], "description": "Hc Phys Exercise Study Incl Hemodynamic Measure", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 278.2, "gross_charge": 428.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100079", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33477", "type": "HCPCS" } ], "description": "Hc Transcath Pulm Valve Plcmnt Perc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100080", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0659T", "type": "HCPCS" } ], "description": "Hc Transcath Intracoronary Nfs Supersat O2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1610.7, "gross_charge": 2478.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100081", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33370", "type": "HCPCS" } ], "description": "Hc Transcath Plcmnt Sbsq Removal Cepd Perq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 268.45, "gross_charge": 413.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100082", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0644T", "type": "HCPCS" } ], "description": "Hc Transcath Removal/Debulk Icar Mass Suction Device Perq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10823.8, "gross_charge": 16652.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100083", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0646T", "type": "HCPCS" } ], "description": "Hc Ttvi/Rplcmnt Prostc Vlv Perq Right Hrt Cath&Angiography", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27888.25, "gross_charge": 42905.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100084", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33952", "type": "HCPCS" } ], "description": "Hc Ecmo Insertion Peripheral Cannula", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26989.3, "gross_charge": 41522.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100085", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33900", "type": "HCPCS" } ], "description": "Hc Perq Pulm Artery Revasularization Initial Normal Connect Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14530.75, "gross_charge": 22355.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100086", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33901", "type": "HCPCS" } ], "description": "Hc Perq Pulm Artery Revasularization Initial Normal Connect Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17436.9, "gross_charge": 26826.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100087", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33902", "type": "HCPCS" } ], "description": "Hc Perq Pulm Artery Revasularization Initial Abnormal Connect Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17221.75, "gross_charge": 26495.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100088", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33903", "type": "HCPCS" } ], "description": "Hc Perq Pulm Artery Revasularization Initial Abnormal Connect Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 20666.1, "gross_charge": 31794.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100089", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "33904", "type": "HCPCS" } ], "description": "Hc Perq Pulm Artery Revasularization Ea Addl Norm/Abnorm Connect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8816.6, "gross_charge": 13564.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100090", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93569", "type": "HCPCS" } ], "description": "Hc Injection Cardiac Cath Selective Pulm Arterial Angio Unilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 975.0, "gross_charge": 1500.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100091", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93573", "type": "HCPCS" } ], "description": "Hc Injection Cardiac Cath Selective Pulm Arterial Angio Bilateral", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1300.0, "gross_charge": 2000.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100092", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93574", "type": "HCPCS" } ], "description": "Hc Injection Cardiac Cath Selective Pulm Venous Angio Each Vein", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 975.0, "gross_charge": 1500.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100093", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "93575", "type": "HCPCS" } ], "description": "Hc Injection Cardiac Cath Selective Pulm Venous Angio Mapcas Each Vessel", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1300.0, "gross_charge": 2000.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100094", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0913T", "type": "HCPCS" } ], "description": "Hc Ptca De Balloon W Ivus Or Oct Single Major Ca Or Branch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10505.3, "gross_charge": 16162.0, "setting": "both" } ] }, { "code_information": [ { "code": "48100095", "type": "CDM" }, { "code": "481", "type": "RC" }, { "code": "0914T", "type": "HCPCS" } ], "description": "Hc Ptca De Balloon Sep Lesion W Ivus Or Oct Single Major Ca Or Branch Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5252.65, "gross_charge": 8081.0, "setting": "both" } ] }, { "code_information": [ { "code": "48200001", "type": "CDM" }, { "code": "482", "type": "RC" }, { "code": "93017", "type": "HCPCS" } ], "description": "Hc Stress Test Tracing Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 759.2, "gross_charge": 1168.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300001", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93303", "type": "HCPCS" } ], "description": "Hc Echo Congen Cardiac Anomaly Comp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1945.45, "gross_charge": 2993.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300002", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93304", "type": "HCPCS" } ], "description": "Hc Echo Congen Cardiac Anomaly Ltd", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1365.65, "gross_charge": 2101.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300003", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93306", "type": "HCPCS" } ], "description": "Hc Echo Complete W Doppler", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1565.2, "gross_charge": 2408.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300005", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93308", "type": "HCPCS" } ], "description": "Hc Echo Limited Or Follow Up", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1121.25, "gross_charge": 1725.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300006", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93312", "type": "HCPCS" } ], "description": "Hc Echo Tee Complete", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1771.25, "gross_charge": 2725.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300007", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93313", "type": "HCPCS" } ], "description": "Hc Echo Tee Probe Plcmt Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1270.75, "gross_charge": 1955.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300008", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93315", "type": "HCPCS" } ], "description": "Hc Echo Tee Congen Cardiac Anomaly Comp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1559.35, "gross_charge": 2399.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300009", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93320", "type": "HCPCS" } ], "description": "Hc Echo Doppler Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 207.35, "gross_charge": 319.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300010", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93321", "type": "HCPCS" } ], "description": "Hc Echo Doppler Limited Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 194.35, "gross_charge": 299.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300011", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93325", "type": "HCPCS" } ], "description": "Hc Echo Color Flow Velocity Mapping Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.3, "gross_charge": 222.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300012", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93350", "type": "HCPCS" } ], "description": "Hc Echo Rest And Stress", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1607.45, "gross_charge": 2473.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300015", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "C8921", "type": "HCPCS" } ], "description": "Hc Echo Congen Cardiac Anomaly Comp W Cont", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1945.45, "gross_charge": 2993.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300017", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "C8923", "type": "HCPCS" } ], "description": "Hc Echo Complete Wo Doppler W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1599.65, "gross_charge": 2461.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300018", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "C8924", "type": "HCPCS" } ], "description": "Hc Echo Limited Or Follow Up W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1121.25, "gross_charge": 1725.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300019", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "C8925", "type": "HCPCS" } ], "description": "Hc Echo Tee Complete W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1771.25, "gross_charge": 2725.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300021", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "C8928", "type": "HCPCS" } ], "description": "Hc Echo Rest And Stress W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1607.45, "gross_charge": 2473.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300023", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "C8929", "type": "HCPCS" } ], "description": "Hc Echo Complete W Doppler W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1565.2, "gross_charge": 2408.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300025", "type": "CDM" }, { "code": "483", "type": "RC" } ], "description": "Hc Athletic Screening Echo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 61.75, "gross_charge": 95.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300026", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93355", "type": "HCPCS" } ], "description": "Hc Echo Tee Guide For Structural Intvn", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2343.9, "gross_charge": 3606.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300029", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93356", "type": "HCPCS" } ], "description": "Hc Myocardial Strain Imaging Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 194.35, "gross_charge": 299.0, "setting": "both" } ] }, { "code_information": [ { "code": "48300030", "type": "CDM" }, { "code": "483", "type": "RC" }, { "code": "93319", "type": "HCPCS" } ], "description": "Hc Echo Tee 3D Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 232.7, "gross_charge": 358.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000001", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29540", "type": "HCPCS" } ], "description": "Hc Strapping Lower Extremity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 852.8, "gross_charge": 1312.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000001_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29540", "type": "HCPCS" } ], "description": "Hc Strapping Lower Extremity", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1705.6, "gross_charge": 2624.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000002", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29580", "type": "HCPCS" } ], "description": "Hc Strapping Unna Boot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 599.95, "gross_charge": 923.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000002_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29580", "type": "HCPCS" } ], "description": "Hc Strapping Unna Boot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1199.9, "gross_charge": 1846.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000003", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29581", "type": "HCPCS" } ], "description": "Hc Applic Multi Layer Comp Sys Leg/Ankle/Foot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 599.95, "gross_charge": 923.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000003_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29581", "type": "HCPCS" } ], "description": "Hc Applic Multi Layer Comp Sys Leg/Ankle/Foot", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 1199.9, "gross_charge": 1846.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000006", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29584", "type": "HCPCS" } ], "description": "Hc Applic Multi Layer Comp Sys Arm Or Hand", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 609.7, "gross_charge": 938.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000007", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29705", "type": "HCPCS" } ], "description": "Hc Cast Removal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2301.65, "gross_charge": 3541.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000007_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "29705", "type": "HCPCS" } ], "description": "Hc Cast Removal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4603.3, "gross_charge": 7082.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000008", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "51720", "type": "HCPCS" } ], "description": "Hc Chemo Bladder Instillation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 621.4, "gross_charge": 956.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000019", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "57500", "type": "HCPCS" } ], "description": "Hc Biopsy Cervix", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3771.95, "gross_charge": 5803.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000021", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "58300", "type": "HCPCS" } ], "description": "Hc Insertion Intrauterine Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2288.0, "gross_charge": 3520.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000022", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "58301", "type": "HCPCS" } ], "description": "Hc Removal Intrauterine Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1524.9, "gross_charge": 2346.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000023", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "59015", "type": "HCPCS" } ], "description": "Hc Chorionic Villus Sampling", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4008.55, "gross_charge": 6167.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000024", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "59025", "type": "HCPCS" } ], "description": "Hc Fetal Non Stress Test", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 497.25, "gross_charge": 765.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000025", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "59070", "type": "HCPCS" } ], "description": "Hc Transabdominal Amnioinfusion W Us Guid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4049.5, "gross_charge": 6230.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000026", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "59074", "type": "HCPCS" } ], "description": "Hc Fetal Fluid Drainage W Us Guidance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3982.55, "gross_charge": 6127.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000027", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "59076", "type": "HCPCS" } ], "description": "Hc Fetal Shunt Placement W Us Guid", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7138.3, "gross_charge": 10982.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000028", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "59200", "type": "HCPCS" } ], "description": "Hc Insert Cervical Dilator", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1169.35, "gross_charge": 1799.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000031", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "62350", "type": "HCPCS" } ], "description": "Hc Impl Revsn Or Repos Intrathecal Or Epid Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4554.55, "gross_charge": 7007.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000036", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64417", "type": "HCPCS" } ], "description": "Hc Injection Anes Axillary Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4628.0, "gross_charge": 7120.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000036_50", "type": "CDM" }, { "code": "361", "type": "RC" }, { "code": "64417", "type": "HCPCS" } ], "description": "Hc Injection Anes Axillary Nerve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 9256.0, "gross_charge": 14240.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000041", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "96523", "type": "HCPCS" } ], "description": "Hc Irrigation Of Impl Ven Access Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 235.95, "gross_charge": 363.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000042", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "97605", "type": "HCPCS" } ], "description": "Hc Negative Pressure Wound Ther Up To 50 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1223.95, "gross_charge": 1883.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000043", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "97606", "type": "HCPCS" } ], "description": "Hc Negative Pressure Wound Ther More Than 50 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2209.35, "gross_charge": 3399.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000044", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "99195", "type": "HCPCS" } ], "description": "Hc Phlebotomy Therapeutic", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 307.45, "gross_charge": 473.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000046", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op New Level 2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000047", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op New Level 3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000048", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op New Level 4", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 138.45, "gross_charge": 213.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000049", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op New Level 5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 169.65, "gross_charge": 261.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000050", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op Estab Level 1", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 83.85, "gross_charge": 129.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000051", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op Estab Level 2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000052", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op Estab Level 3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000053", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op Estab Level 4", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 138.45, "gross_charge": 213.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000054", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "G0463", "type": "HCPCS" } ], "description": "Hc Visit Op Estab Level 5", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 169.65, "gross_charge": 261.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000055", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99384", "type": "HCPCS" } ], "description": "Hc Visit Preventive New 12-17 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000056", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99385", "type": "HCPCS" } ], "description": "Hc Visit Preventive New 18-39 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000057", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99386", "type": "HCPCS" } ], "description": "Hc Visit Preventive New 40-64 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000058", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99387", "type": "HCPCS" } ], "description": "Hc Visit Preventive New >65 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000059", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99394", "type": "HCPCS" } ], "description": "Hc Visit Preventive Estab 12-17 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000060", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99395", "type": "HCPCS" } ], "description": "Hc Visit Preventive Estab 18-39 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000061", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99396", "type": "HCPCS" } ], "description": "Hc Visit Preventive Estab 40-64 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000062", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99397", "type": "HCPCS" } ], "description": "Hc Visit Preventive Estab >65 Yrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 102.7, "gross_charge": 158.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000063", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99401", "type": "HCPCS" } ], "description": "Hc Preventive Med Counsel 15Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 105.3, "gross_charge": 162.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000064", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99402", "type": "HCPCS" } ], "description": "Hc Preventive Med Counsel 30Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 124.8, "gross_charge": 192.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000065", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99403", "type": "HCPCS" } ], "description": "Hc Preventive Med Counsel 45Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.3, "gross_charge": 222.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000066", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99404", "type": "HCPCS" } ], "description": "Hc Preventive Med Counsel 60Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 176.15, "gross_charge": 271.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000067", "type": "CDM" }, { "code": "510", "type": "RC" } ], "description": "Hc Excise Benign Lesion Face", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1297.4, "gross_charge": 1996.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000068", "type": "CDM" }, { "code": "510", "type": "RC" } ], "description": "Hc Excise Benign Lesion S N H F G", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1297.4, "gross_charge": 1996.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000069", "type": "CDM" }, { "code": "510", "type": "RC" } ], "description": "Hc Excise Benign Lesion Tal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1509.3, "gross_charge": 2322.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000076", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "27307", "type": "HCPCS" } ], "description": "Hc Tenotomy Perc Thigh Tendon/Adctr/Hamstrng Mult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3446.95, "gross_charge": 5303.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000076_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "27307", "type": "HCPCS" } ], "description": "Hc Tenotomy Perc Thigh Tendon/Adctr/Hamstrng Mult", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6893.9, "gross_charge": 10606.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000077", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "28008", "type": "HCPCS" } ], "description": "Hc Fasciotomy Foot Toe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3446.95, "gross_charge": 5303.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000077_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "28008", "type": "HCPCS" } ], "description": "Hc Fasciotomy Foot Toe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6893.9, "gross_charge": 10606.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000078", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "64615", "type": "HCPCS" } ], "description": "Hc Botox Inj Chronic Migraine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1292.2, "gross_charge": 1988.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000080", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "C5271", "type": "HCPCS" } ], "description": "Hc Low Cost Appl Skn Grft Trunk Arm Leg 100 Cm 1St 25 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 862.55, "gross_charge": 1327.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000081", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "C5272", "type": "HCPCS" } ], "description": "Hc Low Cost Appl Sg Trnk Arms Legs 100 Cm; Ea Add 25 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 653.9, "gross_charge": 1006.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000082", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "C5273", "type": "HCPCS" } ], "description": "Hc Low Cost Appl Sg Trnk Arm Leg 100Cm Or More 1St 100 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1137.5, "gross_charge": 1750.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000083", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "C5274", "type": "HCPCS" } ], "description": "Hc Low Cost Appl Sg Trnk Arm Leg 100Cm Or More Add 100 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 653.9, "gross_charge": 1006.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000084", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "C5275", "type": "HCPCS" } ], "description": "Hc Low Cost Appl Sg Hhfg To 100 Cm 1St 25 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1240.85, "gross_charge": 1909.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000085", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "C5276", "type": "HCPCS" } ], "description": "Hc Low Cost Appl Sg Hhfg To 100 Cm Ea Addl 25 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 653.9, "gross_charge": 1006.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000089", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "97607", "type": "HCPCS" } ], "description": "Hc Neg Press Disp Non Dme Wnd Ther <50Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 826.15, "gross_charge": 1271.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000090", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "97608", "type": "HCPCS" } ], "description": "Hc Neg Press Wnd Disp Non Dme Ther >50Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 826.15, "gross_charge": 1271.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000091", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "96521", "type": "HCPCS" } ], "description": "Hc Refill And Maintain Portable Pump", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 249.6, "gross_charge": 384.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000095", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "31231", "type": "HCPCS" } ], "description": "Hc Endoscopy Nasal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 532.35, "gross_charge": 819.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000111", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "31233", "type": "HCPCS" } ], "description": "Hc Nasal Endoscopy With Maxillary Sinusoscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1281.8, "gross_charge": 1972.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000114", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "11900", "type": "HCPCS" } ], "description": "Hc Inject Skin Lesions 7 Or Less", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 589.55, "gross_charge": 907.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000116", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "28820", "type": "HCPCS" } ], "description": "Hc Amputation Of Toe; M J", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3122.6, "gross_charge": 4804.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000117", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "27000", "type": "HCPCS" } ], "description": "Hc Tenotomy, Abductor Of Hip, Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3130.4, "gross_charge": 4816.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000117_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "27000", "type": "HCPCS" } ], "description": "Hc Tenotomy, Abductor Of Hip, Percutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 6260.8, "gross_charge": 9632.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000119", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "28232", "type": "HCPCS" } ], "description": "Hc Tenotomy Open Flexor Tendon Toe Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2399.15, "gross_charge": 3691.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000119_50", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "28232", "type": "HCPCS" } ], "description": "Hc Tenotomy Open Flexor Tendon Toe Sgl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 4798.3, "gross_charge": 7382.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "51000120", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "28124", "type": "HCPCS" } ], "description": "Hc Excision Partial Bone Phalanx Toe", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3122.6, "gross_charge": 4804.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000122", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "41010", "type": "HCPCS" } ], "description": "Hc Incision Tongue Fold", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1886.3, "gross_charge": 2902.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000124", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "97610", "type": "HCPCS" } ], "description": "Hc Mist Therapy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 555.1, "gross_charge": 854.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000125", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "27603", "type": "HCPCS" } ], "description": "Hc I And D Deep Abscess Or Hematoma Leg Or Ankle", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4737.85, "gross_charge": 7289.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000126", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "11601", "type": "HCPCS" } ], "description": "Hc Exc Malignant Les Trunk Arm Or Leg 0.6-1.0 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 974.35, "gross_charge": 1499.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000127", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "11623", "type": "HCPCS" } ], "description": "Hc Exc Malignant Les S N H F G 2.1-3.0Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2733.25, "gross_charge": 4205.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000128", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "15853", "type": "HCPCS" } ], "description": "Hc Removal Sutures Or Staples Wo Anes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.8, "gross_charge": 72.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000129", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "15854", "type": "HCPCS" } ], "description": "Hc Removal Sutures And Staples Wo Anes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 46.8, "gross_charge": 72.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000132", "type": "CDM" }, { "code": "510", "type": "RC" } ], "description": "Hc Retail Prp Inj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 327.6, "gross_charge": 504.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000134", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "0272T", "type": "HCPCS" } ], "description": "Hc Device Eval Barostim In Person", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 254.8, "gross_charge": 392.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000135", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "0273T", "type": "HCPCS" } ], "description": "Hc Device Eval Barostim In Person W Programming", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 254.8, "gross_charge": 392.0, "setting": "both" } ] }, { "code_information": [ { "code": "51000137", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "28113", "type": "HCPCS" } ], "description": "Hc Part Removal Of Metatarsal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2601.95, "gross_charge": 4003.0, "setting": "both" } ] }, { "code_information": [ { "code": "53000001", "type": "CDM" }, { "code": "530", "type": "RC" }, { "code": "98925", "type": "HCPCS" } ], "description": "Hc Omt 1-2 Body Regions", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 390.0, "gross_charge": 600.0, "setting": "both" } ] }, { "code_information": [ { "code": "61000004", "type": "CDM" }, { "code": "610", "type": "RC" }, { "code": "0649T", "type": "HCPCS" } ], "description": "Hc Mr Quant Anal Tissue Comp W/ Mri Single Organ Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1121.25, "gross_charge": 1725.0, "setting": "both" } ] }, { "code_information": [ { "code": "61000005", "type": "CDM" }, { "code": "610", "type": "RC" }, { "code": "76014", "type": "HCPCS" } ], "description": "Hc Mr Safety Implant/Fb Assess By Tech Initial 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 48.75, "gross_charge": 75.0, "setting": "both" } ] }, { "code_information": [ { "code": "61000006", "type": "CDM" }, { "code": "610", "type": "RC" }, { "code": "76015", "type": "HCPCS" } ], "description": "Hc Mr Safety Implant/Fb Assess By Tech Ea Addl 30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16.25, "gross_charge": 25.0, "setting": "both" } ] }, { "code_information": [ { "code": "61000007", "type": "CDM" }, { "code": "610", "type": "RC" }, { "code": "76016", "type": "HCPCS" } ], "description": "Hc Mr Safety Determination By Radiologist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 172.25, "gross_charge": 265.0, "setting": "both" } ] }, { "code_information": [ { "code": "61000008", "type": "CDM" }, { "code": "610", "type": "RC" }, { "code": "76018", "type": "HCPCS" } ], "description": "Hc Mr Safety Implant Electronics Prep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 178.75, "gross_charge": 275.0, "setting": "both" } ] }, { "code_information": [ { "code": "61000009", "type": "CDM" }, { "code": "610", "type": "RC" }, { "code": "76019", "type": "HCPCS" } ], "description": "Hc Mr Safety Implant Positioning Or Immobilization", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 117.0, "gross_charge": 180.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100001", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "70336", "type": "HCPCS" } ], "description": "Hc Mri Tmj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1320.8, "gross_charge": 2032.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100001_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "70336", "type": "HCPCS" } ], "description": "Hc Mri Tmj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2641.6, "gross_charge": 4064.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61100002", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70540", "type": "HCPCS" } ], "description": "Hc Mri Orbit Face Neck Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1322.1, "gross_charge": 2034.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100003", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70542", "type": "HCPCS" } ], "description": "Hc Mri Orbit Face Neck W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1561.3, "gross_charge": 2402.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100004", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70543", "type": "HCPCS" } ], "description": "Hc Mri Orbit Face Neck W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1840.8, "gross_charge": 2832.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100005", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70551", "type": "HCPCS" } ], "description": "Hc Mri Brain Stem Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1274.65, "gross_charge": 1961.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100006", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70552", "type": "HCPCS" } ], "description": "Hc Mri Brain Stem W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1638.65, "gross_charge": 2521.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100007", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70553", "type": "HCPCS" } ], "description": "Hc Mri Brain Stem W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2004.6, "gross_charge": 3084.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100008", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70554", "type": "HCPCS" } ], "description": "Hc Mri Brain Functional W Tech Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1626.3, "gross_charge": 2502.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100008_50", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70554", "type": "HCPCS" } ], "description": "Hc Mri Brain Functional W Tech Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3252.6, "gross_charge": 5004.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61100009", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70557", "type": "HCPCS" } ], "description": "Hc Mri Brain During Open Proc Wo Cont", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1978.6, "gross_charge": 3044.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100010", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70558", "type": "HCPCS" } ], "description": "Hc Mri Brain During Open Proc W Cont", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2174.9, "gross_charge": 3346.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100011", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70559", "type": "HCPCS" } ], "description": "Hc Mri Brain During Open Proc W And Wo Cont", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2371.2, "gross_charge": 3648.0, "setting": "both" } ] }, { "code_information": [ { "code": "61100012", "type": "CDM" }, { "code": "611", "type": "RC" }, { "code": "70555", "type": "HCPCS" } ], "description": "Hc Mri Brain Functional W Radiologist", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1870.05, "gross_charge": 2877.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200001", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72141", "type": "HCPCS" } ], "description": "Hc Mri Cervical Spine Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1291.55, "gross_charge": 1987.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200002", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72142", "type": "HCPCS" } ], "description": "Hc Mri Cervical Spine W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1581.45, "gross_charge": 2433.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200003", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72146", "type": "HCPCS" } ], "description": "Hc Mri Thoracic Spine Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1286.35, "gross_charge": 1979.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200004", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72147", "type": "HCPCS" } ], "description": "Hc Mri Thoracic Spine W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1550.9, "gross_charge": 2386.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200005", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72148", "type": "HCPCS" } ], "description": "Hc Mri Lumbar Spine Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1309.1, "gross_charge": 2014.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200006", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72149", "type": "HCPCS" } ], "description": "Hc Mri Lumbar Spine W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1631.5, "gross_charge": 2510.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200007", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72156", "type": "HCPCS" } ], "description": "Hc Mri Cervical Spine W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1864.2, "gross_charge": 2868.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200008", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72157", "type": "HCPCS" } ], "description": "Hc Mri Thoracic Spine W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1935.7, "gross_charge": 2978.0, "setting": "both" } ] }, { "code_information": [ { "code": "61200009", "type": "CDM" }, { "code": "612", "type": "RC" }, { "code": "72158", "type": "HCPCS" } ], "description": "Hc Mri Lumbar Spine W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1842.75, "gross_charge": 2835.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400001", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "71550", "type": "HCPCS" } ], "description": "Hc Mri Chest Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1281.8, "gross_charge": 1972.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400002", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "71551", "type": "HCPCS" } ], "description": "Hc Mri Chest W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1586.0, "gross_charge": 2440.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400003", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "71552", "type": "HCPCS" } ], "description": "Hc Mri Chest W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1889.55, "gross_charge": 2907.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400004", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "72195", "type": "HCPCS" } ], "description": "Hc Mri Pelvis Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1323.4, "gross_charge": 2036.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400005", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "72196", "type": "HCPCS" } ], "description": "Hc Mri Pelvis W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1606.8, "gross_charge": 2472.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400006", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "72197", "type": "HCPCS" } ], "description": "Hc Mri Pelvis W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1891.5, "gross_charge": 2910.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400007", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73218", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Non Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1188.2, "gross_charge": 1828.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400007_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73218", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Non Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2376.4, "gross_charge": 3656.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400008", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73219", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Non Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1381.9, "gross_charge": 2126.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400008_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73219", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Non Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2763.8, "gross_charge": 4252.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400009", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73220", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Non Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1638.65, "gross_charge": 2521.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400009_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73220", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Non Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3277.3, "gross_charge": 5042.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400010", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73221", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1264.25, "gross_charge": 1945.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400010_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73221", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2528.5, "gross_charge": 3890.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400011", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73222", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1381.9, "gross_charge": 2126.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400011_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73222", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2763.8, "gross_charge": 4252.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400012", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73223", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1508.65, "gross_charge": 2321.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400012_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73223", "type": "HCPCS" } ], "description": "Hc Mri Upper Ext Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3017.3, "gross_charge": 4642.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400013", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73718", "type": "HCPCS" } ], "description": "Hc Mri Low Extrem Non Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1285.05, "gross_charge": 1977.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400013_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73718", "type": "HCPCS" } ], "description": "Hc Mri Low Extrem Non Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2570.1, "gross_charge": 3954.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400014", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73719", "type": "HCPCS" } ], "description": "Hc Mri Low Extrem Non Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1353.3, "gross_charge": 2082.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400014_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73719", "type": "HCPCS" } ], "description": "Hc Mri Low Extrem Non Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2706.6, "gross_charge": 4164.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400015", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73720", "type": "HCPCS" } ], "description": "Hc Mri Low Extrem Non Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1702.35, "gross_charge": 2619.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400015_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73720", "type": "HCPCS" } ], "description": "Hc Mri Low Extrem Non Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3404.7, "gross_charge": 5238.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400016", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73721", "type": "HCPCS" } ], "description": "Hc Mri Low Extremity Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1223.95, "gross_charge": 1883.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400016_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73721", "type": "HCPCS" } ], "description": "Hc Mri Low Extremity Joint Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2447.9, "gross_charge": 3766.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400017", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73722", "type": "HCPCS" } ], "description": "Hc Mri Low Extremity Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1446.9, "gross_charge": 2226.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400017_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73722", "type": "HCPCS" } ], "description": "Hc Mri Low Extremity Joint W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2893.8, "gross_charge": 4452.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400018", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73723", "type": "HCPCS" } ], "description": "Hc Mri Low Extremity Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1688.05, "gross_charge": 2597.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400018_50", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "73723", "type": "HCPCS" } ], "description": "Hc Mri Low Extremity Joint W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3376.1, "gross_charge": 5194.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61400019", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "74181", "type": "HCPCS" } ], "description": "Hc Mri Abdomen Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1285.05, "gross_charge": 1977.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400020", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "74182", "type": "HCPCS" } ], "description": "Hc Mri Abdomen W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1629.55, "gross_charge": 2507.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400021", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "74183", "type": "HCPCS" } ], "description": "Hc Mri Abdomen W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2029.3, "gross_charge": 3122.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400022", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "75557", "type": "HCPCS" } ], "description": "Hc Mri Card Morphology And Function Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1167.4, "gross_charge": 1796.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400024", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "75561", "type": "HCPCS" } ], "description": "Hc Mri Card Ltd W And Wo Contrast And Further Seq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1296.75, "gross_charge": 1995.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400025", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "75565", "type": "HCPCS" } ], "description": "Hc Mri Card For Velocity Flow Mapping", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 492.05, "gross_charge": 757.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400026", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "76390", "type": "HCPCS" } ], "description": "Hc Mri Spectroscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1155.05, "gross_charge": 1777.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400030", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77048", "type": "HCPCS" } ], "description": "Hc Mri Breast Unilat W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1624.35, "gross_charge": 2499.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400031", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77046", "type": "HCPCS" } ], "description": "Hc Mri Breast Unilat Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1534.65, "gross_charge": 2361.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400032", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77048", "type": "HCPCS" } ], "description": "Hc Mri Breast Unilat W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1704.95, "gross_charge": 2623.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400033", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77049", "type": "HCPCS" } ], "description": "Hc Mri Breast Bilat W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1638.65, "gross_charge": 2521.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400034", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77047", "type": "HCPCS" } ], "description": "Hc Mri Breast Bilat Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1969.5, "gross_charge": 3030.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400035", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77049", "type": "HCPCS" } ], "description": "Hc Mri Breast Bilat W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2187.25, "gross_charge": 3365.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400036", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77084", "type": "HCPCS" } ], "description": "Hc Mri Bone Marrow Blood Supply", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1537.9, "gross_charge": 2366.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400037", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "76498", "type": "HCPCS" } ], "description": "Hc Mri Radiation Treatment Planning", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 373.1, "gross_charge": 574.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400039", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "C8937", "type": "HCPCS" } ], "description": "Hc Mri Breast Cad Unilat Or Bilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400040", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "0398T", "type": "HCPCS" } ], "description": "Hc Mrgfus Ablation Intracranial Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37679.2, "gross_charge": 57968.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400041", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "75563", "type": "HCPCS" } ], "description": "Hc Mri Cardiac W And Wo Contrast W Stress", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1355.9, "gross_charge": 2086.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400042", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "77049", "type": "HCPCS" } ], "description": "Hc Mri Breast Abbreviated Bilat W & Wo Cont", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 345.8, "gross_charge": 532.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400043", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "0866T", "type": "HCPCS" } ], "description": "Hc Mr Quantitative Analysis Brain Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 575.9, "gross_charge": 886.0, "setting": "both" } ] }, { "code_information": [ { "code": "61400044", "type": "CDM" }, { "code": "614", "type": "RC" }, { "code": "61715", "type": "HCPCS" } ], "description": "Hc Mrghifus Ablation Intracranial Target", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 37679.2, "gross_charge": 57968.0, "setting": "both" } ] }, { "code_information": [ { "code": "61500001", "type": "CDM" }, { "code": "615", "type": "RC" }, { "code": "70544", "type": "HCPCS" } ], "description": "Hc Mra Brain Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 928.2, "gross_charge": 1428.0, "setting": "both" } ] }, { "code_information": [ { "code": "61500002", "type": "CDM" }, { "code": "615", "type": "RC" }, { "code": "70545", "type": "HCPCS" } ], "description": "Hc Mra Brain W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1080.95, "gross_charge": 1663.0, "setting": "both" } ] }, { "code_information": [ { "code": "61500003", "type": "CDM" }, { "code": "615", "type": "RC" }, { "code": "70546", "type": "HCPCS" } ], "description": "Hc Mra Brain W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1233.7, "gross_charge": 1898.0, "setting": "both" } ] }, { "code_information": [ { "code": "61500004", "type": "CDM" }, { "code": "615", "type": "RC" }, { "code": "70547", "type": "HCPCS" } ], "description": "Hc Mra Neck Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 928.2, "gross_charge": 1428.0, "setting": "both" } ] }, { "code_information": [ { "code": "61500005", "type": "CDM" }, { "code": "615", "type": "RC" }, { "code": "70548", "type": "HCPCS" } ], "description": "Hc Mra Neck W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1084.2, "gross_charge": 1668.0, "setting": "both" } ] }, { "code_information": [ { "code": "61500006", "type": "CDM" }, { "code": "615", "type": "RC" }, { "code": "70549", "type": "HCPCS" } ], "description": "Hc Mra Neck W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1240.2, "gross_charge": 1908.0, "setting": "both" } ] }, { "code_information": [ { "code": "61600001", "type": "CDM" }, { "code": "616", "type": "RC" }, { "code": "73725", "type": "HCPCS" } ], "description": "Hc Mra Lower Extremity W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1646.45, "gross_charge": 2533.0, "setting": "both" } ] }, { "code_information": [ { "code": "61600001_50", "type": "CDM" }, { "code": "616", "type": "RC" }, { "code": "73725", "type": "HCPCS" } ], "description": "Hc Mra Lower Extremity W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3292.9, "gross_charge": 5066.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61600002", "type": "CDM" }, { "code": "616", "type": "RC" }, { "code": "73725", "type": "HCPCS" } ], "description": "Hc Mra Lower Extremity Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1387.1, "gross_charge": 2134.0, "setting": "both" } ] }, { "code_information": [ { "code": "61600002_50", "type": "CDM" }, { "code": "616", "type": "RC" }, { "code": "73725", "type": "HCPCS" } ], "description": "Hc Mra Lower Extremity Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2774.2, "gross_charge": 4268.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61600003", "type": "CDM" }, { "code": "616", "type": "RC" }, { "code": "73725", "type": "HCPCS" } ], "description": "Hc Mra Lower Extremity W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1786.85, "gross_charge": 2749.0, "setting": "both" } ] }, { "code_information": [ { "code": "61600003_50", "type": "CDM" }, { "code": "616", "type": "RC" }, { "code": "73725", "type": "HCPCS" } ], "description": "Hc Mra Lower Extremity W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3573.7, "gross_charge": 5498.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61800002", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "73225", "type": "HCPCS" } ], "description": "Hc Mra Upper Extremity W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1797.9, "gross_charge": 2766.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800002_50", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "73225", "type": "HCPCS" } ], "description": "Hc Mra Upper Extremity W Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3595.8, "gross_charge": 5532.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61800003", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "74185", "type": "HCPCS" } ], "description": "Hc Mra Abdomen W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1784.9, "gross_charge": 2746.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800004", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "74185", "type": "HCPCS" } ], "description": "Hc Mra Abdomen Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1439.1, "gross_charge": 2214.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800005", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "74185", "type": "HCPCS" } ], "description": "Hc Mra Abdomen W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2132.0, "gross_charge": 3280.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800006", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "71555", "type": "HCPCS" } ], "description": "Hc Mra Chest W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1554.15, "gross_charge": 2391.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800007", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "71555", "type": "HCPCS" } ], "description": "Hc Mra Chest Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1399.45, "gross_charge": 2153.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800008", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "71555", "type": "HCPCS" } ], "description": "Hc Mra Chest W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1726.4, "gross_charge": 2656.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800009", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "72198", "type": "HCPCS" } ], "description": "Hc Mra Pelvis W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1693.25, "gross_charge": 2605.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800010", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "72198", "type": "HCPCS" } ], "description": "Hc Mra Pelvis Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1399.45, "gross_charge": 2153.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800011", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "72198", "type": "HCPCS" } ], "description": "Hc Mra Pelvis W And Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1987.05, "gross_charge": 3057.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800012", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "73225", "type": "HCPCS" } ], "description": "Hc Mra Upper Extremity Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1184.3, "gross_charge": 1822.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800012_50", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "73225", "type": "HCPCS" } ], "description": "Hc Mra Upper Extremity Wo Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2368.6, "gross_charge": 3644.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "61800013", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "73225", "type": "HCPCS" } ], "description": "Hc Mra Upper Extremity W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1433.25, "gross_charge": 2205.0, "setting": "both" } ] }, { "code_information": [ { "code": "61800013_50", "type": "CDM" }, { "code": "618", "type": "RC" }, { "code": "73225", "type": "HCPCS" } ], "description": "Hc Mra Upper Extremity W Contrast", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 2866.5, "gross_charge": 4410.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "62400089", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1725", "type": "HCPCS" } ], "description": "Hc Ide G130007 Pro1140762 Brk", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400097", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide G130005 Pro 1143399 Evas 1 Nellix Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5362.5, "gross_charge": 8250.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400124", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G140059 Pro1148561 Evolut R", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21450.0, "gross_charge": 33000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400128", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G140056 Pro 1149152", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4225.0, "gross_charge": 6500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400129", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G140090 Pro11499986 Repriseiii", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16250.0, "gross_charge": 25000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400135", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G130286 Proj 1157910 Web-It Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400136", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G130286 Proj 1157910 Web-It Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400139", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G120169 Pro 1136831 Evolutr Corevalve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21450.0, "gross_charge": 33000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400140", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150210 Project 20151943 Reduce Lap-Hf", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400141", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150121 Pro 1161749 Surveilsurmodics", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400156", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G160022 Pro 1165258 Evolut R 23,26,29Mm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21450.0, "gross_charge": 33000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400159", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G160039 Pro 1165489 Tavr 2.0", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21450.0, "gross_charge": 33000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400160", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G160055 Pro02768402 Transcath Mitral Valve Repl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400162", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1876", "type": "HCPCS" } ], "description": "Hc Ide G130221 Pro Ohi-15-00603 Crest 2 Xact", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1072.5, "gross_charge": 1650.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400165", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1884", "type": "HCPCS" } ], "description": "Hc Ide G130221 Pro Ohi-15-00603 Crest 2 Nav 6 Filter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 958.75, "gross_charge": 1475.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400168", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1884", "type": "HCPCS" } ], "description": "Hc Ide G130221 Pro Ohi-15-00603 Crest 2 Moma Ultra Filter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 971.75, "gross_charge": 1495.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400173", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1733", "type": "HCPCS" } ], "description": "Hc Ide G130084 Converge Epi-Sense Coag System Visitrax", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4563.0, "gross_charge": 7020.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400175", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1769", "type": "HCPCS" } ], "description": "Hc Ide G150107 Amaze Guidewire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 715.0, "gross_charge": 1100.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400176", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C2628", "type": "HCPCS" } ], "description": "Hc Ide G150107 Amaze Occlusion Balloon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 422.5, "gross_charge": 650.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400177", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150107 Amaze Suture Cutter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 260.0, "gross_charge": 400.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400178", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150107 Amaze Soft Guide Cannula", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 195.0, "gross_charge": 300.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400179", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150107 Amaze Tensure Suture Tightener", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 130.0, "gross_charge": 200.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400180", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G160074 Madit S-Icd Emblem", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11050.0, "gross_charge": 17000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400181", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G160074 Madit S-Icd Subq Electrode Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2600.0, "gross_charge": 4000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400184", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G160163 Abre", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 260.0, "gross_charge": 400.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400187", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G160144 Toba Ii Btk Nitinol Tacks", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400188", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G160020 Apollo Percutaneous Valve System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 29250.0, "gross_charge": 45000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400189", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G170113 Wavecrest Left Atrial Appendage Occlusion System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400190", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide G160227 Optimize Svelte Coronary Stent System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400191", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150101 Control Htn Rox Coupler", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400192", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C2623", "type": "HCPCS" } ], "description": "Hc Ide G150121 Transcend Surveil Drug Coated Balloon Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400193", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G170251 Wing-It Wingman Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400194", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide G150057 Aaa 13-03 Gore Excluder Trunk-Ipsi Leg Endo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6175.0, "gross_charge": 9500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400195", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide G150057 Aaa 13-03 Gore Excluder Aortic Ext Endo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1625.0, "gross_charge": 2500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400197", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150107 Amaze Lariat-Rs Suture Delivery Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5167.5, "gross_charge": 7950.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400198", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Ide G180004 Tiger Revascularzation Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400199", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150200 Pinnacle Flex Watchman Closure Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400200", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G160259 Early Tavr Sapien 3 Valve System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19500.0, "gross_charge": 30000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400201", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G160171 Asap Too Watchman Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11050.0, "gross_charge": 17000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400202", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G160171 Asap Too Watchman Delivery Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 650.0, "gross_charge": 1000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400203", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C2624", "type": "HCPCS" } ], "description": "Hc Ide G170258 Guide Hf Cardiomems Hf System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13975.0, "gross_charge": 21500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400204", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G180045 Exceed Edwards Centera Heart Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21125.0, "gross_charge": 32500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400205", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide G180073 Saval Des Btk Vascular Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400206", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G160022 Low Risk Bicuspid Tavr System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 21450.0, "gross_charge": 33000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400207", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide G140178 Onyx Resolute Coronary Stent A", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 536.25, "gross_charge": 825.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400208", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide G140178 Onyx Resolute Coronary Stent B", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 585.0, "gross_charge": 900.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400209", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1896", "type": "HCPCS" } ], "description": "Hc Ide G170215 Unpinning Icd Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400210", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G170215 Unpinning Accessory Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400211", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1732", "type": "HCPCS" } ], "description": "Hc Ide G170215 Unpinning Mapping Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400212", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1759", "type": "HCPCS" } ], "description": "Hc Ide G170215 Unpinning Ice Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400213", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G170215 Unpinning Ensite Patch", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400214", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G170215 Unpinning Cess System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400215", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G180106 Foldax Polymer Aortic Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400216", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G190051 Accurate Ide Neo2 Aortic Valve System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 18200.0, "gross_charge": 28000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400217", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G180270 Option Watchman Procedure Charge", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13000.0, "gross_charge": 20000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400218", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G170166 Clasp 2D2F Implant System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19500.0, "gross_charge": 30000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400219", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Ide G170166 Clasp 2D2F Guide Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400220", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G170166 Clasp 2D2F Stabilizer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400221", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G170118 Triluminate Clip Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19500.0, "gross_charge": 30000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400222", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G170118 Triluminate Guide Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400223", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G170118 Triluminate Clip Addtl", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400224", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G180270 Option Watchman Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400225", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G180270 Option Watchman Delivery Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400226", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1722", "type": "HCPCS" } ], "description": "Hc Ide G190186 Ev Icd Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 14111.5, "gross_charge": 21710.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400227", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1896", "type": "HCPCS" } ], "description": "Hc Ide G190186 Ev Icd Icd Lead", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4091.75, "gross_charge": 6295.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400228", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G190186 Ev Icd Sternal Tunneling Tool", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 617.5, "gross_charge": 950.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400229", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G190186 Ev Icd Transverse Tunneling Tool", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 617.5, "gross_charge": 950.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400230", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Ide G190186 Ev Icd Safesheath Ii", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 61.75, "gross_charge": 95.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400231", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G170215 Unpinning Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400232", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1769", "type": "HCPCS" } ], "description": "Hc Ide G170215 Unpinning Guidewire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400233", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G170215 Unpinning Introducer", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400234", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G170215 Unpinning Diagnostic Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400235", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Ide G190099 Prost Preset Thrombectomy Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3770.0, "gross_charge": 5800.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400236", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G200119 Ttvr Efs Intrepid Trnscth Tricuspid Valve Rplcmt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400237", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Ide G190069 Endolow Embotrap Ii Revasc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3900.0, "gross_charge": 6000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400239", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1876", "type": "HCPCS" } ], "description": "Hc Ide G190030 Vivid Vesper Vesper Duo Venous Stent System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400240", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G190111 Life Btk Esprit Btk Everolimus Eluting Bio Scaffold System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400241", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C2623", "type": "HCPCS" } ], "description": "Hc Ide G180263 Iclas Af Cryoablation System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400242", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150035 Align Tavr - Transfemoral Jenavalve Pericardial Tavr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400243", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G150035 Align Tavr Accessories (Delivery Cath & Loading Tool)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.49, "gross_charge": 0.75, "setting": "both" } ] }, { "code_information": [ { "code": "62400244", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G180106 Foldax Polymer Mitral Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400245", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G200310 Membrane Trufill Nbca Liquid Emolic System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400246", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1786", "type": "HCPCS" } ], "description": "Hc Ide G210339 Aveir Dual Chamber Leadless Pacemaker", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400248", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1764", "type": "HCPCS" } ], "description": "Hc Ide #G200110 Alleviate Hf - Reveal Linq Insertalbe Cardiac Monitor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400249", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G200110 Alleviate Hf - Reveal Linq Accessories", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400250", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1888", "type": "HCPCS" } ], "description": "Hc Ide #G220034 Admire - Ire Ablation System Varipulse Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400251", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1817", "type": "HCPCS" } ], "description": "Hc Ide G210167 Occluflex - Flex Ii Pfo Occluder Device", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400252", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G210167 Occluflex - Occlutech Pistol Pusher Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400253", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G200106 Champion-Af Watchman Flex", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 11050.0, "gross_charge": 17000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400254", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G200106 Champion-Af Watchman Flex Delivery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 650.0, "gross_charge": 1000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400255", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G150035 Align Tavr - Transfemoral Jenavalve Pericardial Tavr System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 21125.0, "gross_charge": 32500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400256", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G210002 Summit Max - Route 92 Medical Base Camp Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400257", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G210002 Summit Max - Accessories", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400258", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C2630", "type": "HCPCS" } ], "description": "Hc Ide G210170 Sphere-9 Mapping And Ablation Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400259", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1726", "type": "HCPCS" } ], "description": "Hc Ide G220079 Farawave Pfa Balloon Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4225.0, "gross_charge": 6500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400260", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1726", "type": "HCPCS" } ], "description": "Hc Ide G220079 Farapoint Pfa Point Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2112.5, "gross_charge": 3250.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400261", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1766", "type": "HCPCS" } ], "description": "Hc Ide G220079 Faradrive Steerable Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 910.0, "gross_charge": 1400.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400262", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G220079 Farastar Catheter Connection Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 552.5, "gross_charge": 850.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400263", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G210083 Innovalve Twist Efs - Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400264", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G210083 Innovalve Twist Efs - Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400265", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1824", "type": "HCPCS" } ], "description": "Hc Ide G200042 Aim Higher - Optimizer Smart Mini System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 16900.0, "gross_charge": 26000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400266", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1786", "type": "HCPCS" } ], "description": "Hc Ide G200319 Modular Atp - Empower System - Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6337.5, "gross_charge": 9750.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400267", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1786", "type": "HCPCS" } ], "description": "Hc Ide G200319 Modular Atp - Empower Pacemaker And Delivery Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400268", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Ide G200319 Modular Atp - Empower Introducer Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400269", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G200319 Modular Atp - Empower Accessory", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400270", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G200319 Modular Atp - Empower Retrieval System - Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2275.0, "gross_charge": 3500.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400271", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Ide G200319 Modular Atp - Empower Retrieval Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400272", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1773", "type": "HCPCS" } ], "description": "Hc Ide G200319 Modular Atp - Empower Single-Loop Snare", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400273", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1773", "type": "HCPCS" } ], "description": "Hc Ide G200319 Modular Atp - Empower Tri-Loop Snare", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400274", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G210339 - Aveir - Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400275", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1894", "type": "HCPCS" } ], "description": "Hc Ide #G210339 - Aveir - Introducer Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400276", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide #G180189-S016 Conform Pivotal Plug And Delivery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400277", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G180189-S016 Conform Pivotal Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400278", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G180189-S016 Conform Pivotal Loader", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400279", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide #G220087 Deeper Reveal - Bare Temporary Spur Stent System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400280", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G220087 Deeper Reveal - Bare Temporary Spur Stent Delivery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400281", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1874", "type": "HCPCS" } ], "description": "Hc Ide #G220109 Gore Viafort - Gore Viafort Vascular Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400282", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G220109 Gore Viafort - Gore Viafort Vascular Stent Delivery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400283", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide# G190051 - Acurate Ide Prime Xl Aortic Valve - Initial", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18200.0, "gross_charge": 28000.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400284", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide# G190051 - Acurate Ide Prime Xl Aortic Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400285", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide# G190051 - Acurate Ide Prime Xl Delivery Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400286", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide# G190051 - Acurate Ide Prime Xl Loader", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "62400287", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G150036 Spyral Affirm - Symplicity Spyral Renal Denervation Catheter System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400288", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Ide #G220033 Protect H2H - Embolic Protection Device Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400289", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide #G200119 Ttvr Efs - Delivery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400290", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G200119 Ttvr Efs - Loader", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400291", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1769", "type": "HCPCS" } ], "description": "Hc Ide #G220207 - Telltale Electosurgical Guidewire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400292", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G220207 - Telltale Electosurgical Accessories", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400293", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1725", "type": "HCPCS" } ], "description": "Hc Ide G200051 Aspire Ph Balloon Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400294", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide G200051 Aspire Ph Delivery System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400295", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G200051 Aspire Ph Accessories", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400296", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C2623", "type": "HCPCS" } ], "description": "Hc Ide G210320 Selution Slr De Balloon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400297", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G220096 Escape-Mevo Solitaire X", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400298", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide# G190051 - Acurate Ide Prime Xl Isleeve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400299", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1769", "type": "HCPCS" } ], "description": "Hc Ide# G190051 - Acurate Ide Prime Xl Wire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400300", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1757", "type": "HCPCS" } ], "description": "Hc Ide G230027/ S001 - Aventus Aspiration Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400301", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G230027/ S001 - Aventus Clot Management System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400302", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G200119 Ttvr Efs - Accessory", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400303", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1732", "type": "HCPCS" } ], "description": "Hc Ide #G230170 Smartpulse Paf - Thermocool Smarttouch Sf Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400304", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1733", "type": "HCPCS" } ], "description": "Hc Ide G230249 Avant Guard - Farawave Pfa Balloon Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4292.7, "gross_charge": 6604.16, "setting": "both" } ] }, { "code_information": [ { "code": "62400305", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1766", "type": "HCPCS" } ], "description": "Hc Ide G230249 Avant Guard - Faradrive Steerable Sheath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 865.2, "gross_charge": 1331.07, "setting": "both" } ] }, { "code_information": [ { "code": "62400306", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G230249 Avant Guard - Farastar Catheter Connection Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 133.11, "gross_charge": 204.78, "setting": "both" } ] }, { "code_information": [ { "code": "62400307", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C2628", "type": "HCPCS" } ], "description": "Hc Ide G180213/ S028 - Venus Hf Precardia Balloon Occlusion Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400308", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G180213/ S028 - Venus Hf Accessory", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400309", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1876", "type": "HCPCS" } ], "description": "Hc Ide #G200007 - Performance Iii Neuroguard Iep Direct System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2595.59, "gross_charge": 3993.21, "setting": "both" } ] }, { "code_information": [ { "code": "62400310", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G200007 - Performance Iii Neuroguard Direct Access Kit", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1663.84, "gross_charge": 2559.75, "setting": "both" } ] }, { "code_information": [ { "code": "62400311", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide #G220093 Atriclip Excluder", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 765.36, "gross_charge": 1177.48, "setting": "both" } ] }, { "code_information": [ { "code": "62400312", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide #G220093 Atriclip Exclusion Flexv Series", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1197.96, "gross_charge": 1843.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400318", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G230284 Picante - Kardion Cory P4 System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 16638.38, "gross_charge": 25597.5, "setting": "both" } ] }, { "code_information": [ { "code": "62400319", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1725", "type": "HCPCS" } ], "description": "Hc Ide G240108 - Power Pad Ii Pulse Periph Ivl Balloon Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400320", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide Proj Ide G220141 - Laax Laminar Left Atrial Appendage Closure System", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400321", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "L8699", "type": "HCPCS" } ], "description": "Hc Ide G230146 Envision - Navitor Valve", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 17470.3, "gross_charge": 26877.38, "setting": "both" } ] }, { "code_information": [ { "code": "62400322", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide G230146 Envision - Navitor Loader", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 332.77, "gross_charge": 511.95, "setting": "both" } ] }, { "code_information": [ { "code": "62400323", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1889", "type": "HCPCS" } ], "description": "Hc Ide G230146 Envision - Flexnav Delivery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 998.3, "gross_charge": 1535.85, "setting": "both" } ] }, { "code_information": [ { "code": "62400324", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1769", "type": "HCPCS" } ], "description": "Hc Ide #G150036 Spyral Affirm - Guidewire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400325", "type": "CDM" }, { "code": "624", "type": "RC" }, { "code": "C1887", "type": "HCPCS" } ], "description": "Hc Ide #G150036 Spyral Affirm - Guidecath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400326", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G190234 Ultra-Hfib-Redo - Paradise Catheter", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400327", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G190234 Ultra-Hfib-Redo - Paradise Cartridge62400327", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400328", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide #G190234 Ultra-Hfib-Redo - Paradise Connection Cable", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "62400329", "type": "CDM" }, { "code": "624", "type": "RC" } ], "description": "Hc Ide# G230119 Picasso", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 0.66, "gross_charge": 1.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_250", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28.4, "gross_charge": 43.7, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_636", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 83.8, "gross_charge": 128.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_90371_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90371", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 192.66, "gross_charge": 296.4, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_90375_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90375", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 832.08, "gross_charge": 1280.13, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_90380_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90380", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1449.07, "gross_charge": 2229.34, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_90396_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90396", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7366.21, "gross_charge": 11332.63, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_90746_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90746", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 105.73, "gross_charge": 162.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_A9589_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "A9589", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4475.26, "gross_charge": 6885.01, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9047_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9047", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2106.09, "gross_charge": 3240.14, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9088_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9088", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.44, "gross_charge": 3.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9113_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9113", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30.17, "gross_charge": 46.42, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9143_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9143", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.79, "gross_charge": 5.83, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9163_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9163", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 177.18, "gross_charge": 272.58, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9254_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9254", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.5, "gross_charge": 0.77, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9290_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9290", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.2, "gross_charge": 8.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9399_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9399", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4577.41, "gross_charge": 7042.17, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_C9460_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9460", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 60.66, "gross_charge": 93.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0129_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0129", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 189.34, "gross_charge": 291.3, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0131_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0131", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.45, "gross_charge": 0.69, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0132_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0132", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.33, "gross_charge": 3.59, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0133_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0133", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.27, "gross_charge": 0.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0134_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0134", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0135_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0135", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.33, "gross_charge": 0.51, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0136_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0136", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0137_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0137", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.38, "gross_charge": 0.59, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0153_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0153", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.91, "gross_charge": 6.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0171_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0171", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.56, "gross_charge": 5.48, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0173_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0173", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.66, "gross_charge": 4.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0174_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0174", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.33, "gross_charge": 6.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0180_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0180", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 639.26, "gross_charge": 983.48, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0209_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0209", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.74, "gross_charge": 4.21, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0222_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0222", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 239.76, "gross_charge": 368.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0225_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0225", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10212.88, "gross_charge": 15712.13, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0248_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0248", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 20.42, "gross_charge": 31.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0257_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0257", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26.88, "gross_charge": 41.36, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0270_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0270", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.75, "gross_charge": 8.84, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0278_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0278", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.02, "gross_charge": 7.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0280_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0280", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 39.24, "gross_charge": 60.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0282_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0282", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.02, "gross_charge": 7.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0283_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0283", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.72, "gross_charge": 11.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0285_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0285", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 141.69, "gross_charge": 217.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0289_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0289", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 77.12, "gross_charge": 118.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0290_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.13, "gross_charge": 12.51, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0295_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0295", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.3, "gross_charge": 29.7, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0330_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0330", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.35, "gross_charge": 12.84, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0360_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0360", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 27.64, "gross_charge": 42.53, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0391_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0391", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 148.83, "gross_charge": 228.97, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0456_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0456", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30.82, "gross_charge": 47.42, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0457_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0457", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9.02, "gross_charge": 13.87, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0461_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0461", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.79, "gross_charge": 1.21, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0475_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0475", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 612.55, "gross_charge": 942.38, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0476_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0476", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 217.13, "gross_charge": 334.05, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0485_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0485", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12.97, "gross_charge": 19.95, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0490_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0490", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 117.01, "gross_charge": 180.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0491_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0491", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 57.26, "gross_charge": 88.09, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0500_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0500", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 57.1, "gross_charge": 87.85, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0515_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0515", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 63.72, "gross_charge": 98.03, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0517_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0517", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 538.18, "gross_charge": 827.97, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0561_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0561", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 76.91, "gross_charge": 118.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0565_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0565", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 107.67, "gross_charge": 165.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0583_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0583", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.79, "gross_charge": 1.22, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0585_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0585", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 21.76, "gross_charge": 33.47, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0594_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0594", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.72, "gross_charge": 2.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0597_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0597", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 234.74, "gross_charge": 361.14, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0612_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0612", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0613_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0613", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.49, "gross_charge": 0.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0630_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0630", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2210.98, "gross_charge": 3401.5, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0637_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0637", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17.27, "gross_charge": 26.57, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0640_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0640", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9.27, "gross_charge": 14.26, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0650_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0650", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 23.63, "gross_charge": 36.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0651_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0651", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 24.61, "gross_charge": 37.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0665_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0665", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.2, "gross_charge": 0.3, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0670_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0670", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 23.77, "gross_charge": 36.57, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0689_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0689", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 16.43, "gross_charge": 25.28, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0690_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0690", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 25.32, "gross_charge": 38.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0692_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0692", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 15.57, "gross_charge": 23.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0694_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0694", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 25.8, "gross_charge": 39.69, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0695_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0695", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 25.79, "gross_charge": 39.67, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0696_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12.22, "gross_charge": 18.8, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0699_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0699", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.03, "gross_charge": 10.82, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0701_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0701", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18.72, "gross_charge": 28.8, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0702_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0702", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 35.57, "gross_charge": 54.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0703_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0703", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 22.46, "gross_charge": 34.56, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0706_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0706", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.74, "gross_charge": 11.9, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0712_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0712", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.28, "gross_charge": 17.36, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0713_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0713", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.17, "gross_charge": 17.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0714_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0714", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 309.49, "gross_charge": 476.14, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0717_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0717", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 48.13, "gross_charge": 74.04, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0735_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0735", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26.14, "gross_charge": 40.21, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0736_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0736", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 20.02, "gross_charge": 30.8, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0737_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0737", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.95, "gross_charge": 30.69, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0740_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0740", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1591.54, "gross_charge": 2448.52, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0743_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0743", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 22.45, "gross_charge": 34.54, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0744_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0744", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 23.96, "gross_charge": 36.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0780_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0780", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0834_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0834", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 112.44, "gross_charge": 172.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0874_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0874", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.15, "gross_charge": 0.23, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0875_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0875", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 56.3, "gross_charge": 86.61, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0877_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0877", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.27, "gross_charge": 0.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0878_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0878", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.15, "gross_charge": 0.23, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0881_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0881", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.29, "gross_charge": 17.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0883_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0883", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.89, "gross_charge": 5.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0884_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0884", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0885_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0885", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 40.73, "gross_charge": 62.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0888_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0888", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.82, "gross_charge": 18.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0894_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0894", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.16, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0896_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0896", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 130.1, "gross_charge": 200.15, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0897_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0897", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 91.33, "gross_charge": 140.51, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0898_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0898", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.97, "gross_charge": 7.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J0899_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0899", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.93, "gross_charge": 7.58, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1010_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1010", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.86, "gross_charge": 1.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1030_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1030", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 34.98, "gross_charge": 53.82, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1040_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1040", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 45.77, "gross_charge": 70.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1050_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1050", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.11, "gross_charge": 1.71, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1071_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1071", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.3, "gross_charge": 0.46, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1100_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1100", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.88, "gross_charge": 5.97, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1110_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1110", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 112.5, "gross_charge": 173.07, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1120_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1120", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 100.67, "gross_charge": 154.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1160_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1160", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 32.86, "gross_charge": 50.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1162_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1162", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14943.86, "gross_charge": 22990.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1165_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1165", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.7, "gross_charge": 13.39, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1170_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1170", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30.17, "gross_charge": 46.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1171_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.74, "gross_charge": 7.3, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1200_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1200", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 23.72, "gross_charge": 36.5, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1205_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1205", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 132.92, "gross_charge": 204.49, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1230_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1230", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 71.94, "gross_charge": 110.67, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1250_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1250", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 34.44, "gross_charge": 52.99, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1265_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1265", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.9, "gross_charge": 10.61, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1300_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1300", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 488.14, "gross_charge": 750.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1303_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1303", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 595.46, "gross_charge": 916.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1305_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1305", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 365.92, "gross_charge": 562.95, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1306_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1306", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 39.47, "gross_charge": 60.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1325_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1325", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 78.31, "gross_charge": 120.47, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1335_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1335", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 56.54, "gross_charge": 86.99, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1364_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1364", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 108.29, "gross_charge": 166.6, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1380_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1380", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 63.5, "gross_charge": 97.7, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1410_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1410", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1198.83, "gross_charge": 1844.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1430_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1430", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1449.86, "gross_charge": 2230.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1438_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1438", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.45, "gross_charge": 0.69, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1439_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1439", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.38, "gross_charge": 6.74, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1450_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1450", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28.15, "gross_charge": 43.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1451_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1451", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.54, "gross_charge": 30.06, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1453_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1453", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.77, "gross_charge": 1.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1459_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1459", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 100.83, "gross_charge": 155.12, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1561_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1561", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 154.49, "gross_charge": 237.68, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1568_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1568", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 126.1, "gross_charge": 194.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1569_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1569", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 99.65, "gross_charge": 153.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1570_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1570", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 137.59, "gross_charge": 211.67, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1580_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1580", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 13.46, "gross_charge": 20.7, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1595_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1595", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 168.54, "gross_charge": 259.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1596_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1596", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9.61, "gross_charge": 14.78, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1602_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1602", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 112.63, "gross_charge": 173.27, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1610_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1610", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 459.28, "gross_charge": 706.59, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1611_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1611", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 397.56, "gross_charge": 611.63, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1630_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1630", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 22.91, "gross_charge": 35.24, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1631_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1631", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 32.81, "gross_charge": 50.47, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1640_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1640", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 101.93, "gross_charge": 156.81, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1642_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1642", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.47, "gross_charge": 0.73, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1643_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1643", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.6, "gross_charge": 4.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1644_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1650_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.97, "gross_charge": 12.26, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1652_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1652", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10.0, "gross_charge": 15.38, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1670_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1670", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1836.49, "gross_charge": 2825.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1720_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1720", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 59.67, "gross_charge": 91.8, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1742_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1742", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 299.01, "gross_charge": 460.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1744_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1744", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 173.56, "gross_charge": 267.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1745_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1745", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 149.92, "gross_charge": 230.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1750_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1750", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 56.58, "gross_charge": 87.05, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1756_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1756", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.27, "gross_charge": 1.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1790_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1790", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 31.07, "gross_charge": 47.8, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1800_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1800", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 48.71, "gross_charge": 74.94, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1805_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1805", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.5, "gross_charge": 2.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1823_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1823", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1133.55, "gross_charge": 1743.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1833_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1833", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.3, "gross_charge": 5.08, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1836_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1836", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.89, "gross_charge": 1.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1885_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1885", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17.84, "gross_charge": 27.45, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1920_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1920", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12.53, "gross_charge": 19.27, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1921_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1921", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.08, "gross_charge": 10.89, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1939_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1939", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1940_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1940", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10.89, "gross_charge": 16.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1943_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1943", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.44, "gross_charge": 3.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1944_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1944", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.24, "gross_charge": 3.45, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1950_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1950", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4252.53, "gross_charge": 6542.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1953_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1953", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.32, "gross_charge": 0.5, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1955_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1955", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 124.79, "gross_charge": 191.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1956_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1956", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 16.8, "gross_charge": 25.84, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J1980_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1980", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 102.78, "gross_charge": 158.13, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2001_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2001", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.26, "gross_charge": 0.4, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2020_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2020", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 21.3, "gross_charge": 32.77, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2060_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2060", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 23.52, "gross_charge": 36.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2150_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2150", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26.29, "gross_charge": 40.44, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2175_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2175", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 31.12, "gross_charge": 47.87, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2182_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2182", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 121.71, "gross_charge": 187.24, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2183_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2183", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.03, "gross_charge": 9.28, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2184_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2184", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.84, "gross_charge": 13.6, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2185_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2185", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.85, "gross_charge": 5.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2186_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2186", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.01, "gross_charge": 10.79, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2210_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2210", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 84.92, "gross_charge": 130.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2247_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2247", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.98, "gross_charge": 1.5, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2248_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2248", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.25, "gross_charge": 1.92, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2250_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12.28, "gross_charge": 18.9, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2251_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2251", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.88, "gross_charge": 1.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2260_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2260", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 13.56, "gross_charge": 20.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2265_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2265", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.07, "gross_charge": 12.42, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2270_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28.94, "gross_charge": 44.53, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2272_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2272", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 29.03, "gross_charge": 44.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2274_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2274", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26.65, "gross_charge": 41.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2300_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2300", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30.67, "gross_charge": 47.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2305_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2305", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.7, "gross_charge": 18.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2310_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2310", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 37.15, "gross_charge": 57.15, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2315_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2315", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.68, "gross_charge": 8.74, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2323_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2323", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 73.16, "gross_charge": 112.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2327_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2327", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 22.21, "gross_charge": 34.17, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2329_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2329", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 161.8, "gross_charge": 248.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2350_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2350", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 159.07, "gross_charge": 244.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2353_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2353", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 736.9, "gross_charge": 1133.7, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2356_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2356", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 65.4, "gross_charge": 100.62, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2357_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2357", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 154.47, "gross_charge": 237.65, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2359_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2359", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.25, "gross_charge": 8.08, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2360_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2360", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 67.52, "gross_charge": 103.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2371_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2371", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2401_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2401", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.17, "gross_charge": 0.26, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2404_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2404", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.56, "gross_charge": 0.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2405_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2405", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.77, "gross_charge": 8.87, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2407_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2407", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 92.18, "gross_charge": 141.82, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2426_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2426", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9.96, "gross_charge": 15.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2427_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2427", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 39.57, "gross_charge": 60.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2430_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2430", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 44.3, "gross_charge": 68.16, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2469_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2469", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.79, "gross_charge": 7.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2470_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2470", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 27.16, "gross_charge": 41.78, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2471_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2471", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30.71, "gross_charge": 47.25, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2501_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2501", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.94, "gross_charge": 22.99, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2506_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2506", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 850.01, "gross_charge": 1307.71, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2507_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2507", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10584.86, "gross_charge": 16284.4, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2515_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2515", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 117.87, "gross_charge": 181.34, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2540_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.21, "gross_charge": 17.24, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2543_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2543", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 29.46, "gross_charge": 45.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2547_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2547", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.26, "gross_charge": 8.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2560_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2560", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 106.01, "gross_charge": 163.09, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2562_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2562", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 845.6, "gross_charge": 1300.92, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2590_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2590", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18.63, "gross_charge": 28.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2597_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2597", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 16.22, "gross_charge": 24.95, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2598_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2598", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.49, "gross_charge": 11.52, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2599_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2599", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.93, "gross_charge": 7.58, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2679_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2679", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28.44, "gross_charge": 43.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2680_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2680", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 33.48, "gross_charge": 51.5, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2690_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2690", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 210.07, "gross_charge": 323.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2704_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2704", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.05, "gross_charge": 1.61, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2710_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2710", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.06, "gross_charge": 9.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2720_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2720", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.96, "gross_charge": 9.17, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2760_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2760", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1318.69, "gross_charge": 2028.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2765_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2765", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 24.83, "gross_charge": 38.2, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2783_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2783", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1008.85, "gross_charge": 1552.07, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2785_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2785", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 30.93, "gross_charge": 47.58, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2790_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2790", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 420.27, "gross_charge": 646.57, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2791_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2791", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17.23, "gross_charge": 26.51, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2794_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2794", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 38.32, "gross_charge": 58.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2795_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.46, "gross_charge": 0.71, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2796_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2796", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 319.53, "gross_charge": 491.59, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2800_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2800", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 39.6, "gross_charge": 60.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2805_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2805", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 106.36, "gross_charge": 163.63, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2806_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2806", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 99.01, "gross_charge": 152.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2916_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2916", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.08, "gross_charge": 10.89, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2919_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.13, "gross_charge": 3.27, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2920_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2920", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 36.31, "gross_charge": 55.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2930_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2930", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 32.21, "gross_charge": 49.56, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J2997_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 245.82, "gross_charge": 378.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3010_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12.54, "gross_charge": 19.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3032_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3032", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 59.24, "gross_charge": 91.14, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3055_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3055", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 185.62, "gross_charge": 285.57, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3101_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3101", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 360.29, "gross_charge": 554.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3105_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3105", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 23.6, "gross_charge": 36.3, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3111_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3111", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 35.46, "gross_charge": 54.56, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3230_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3230", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 137.04, "gross_charge": 210.83, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3240_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3240", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6976.99, "gross_charge": 10733.83, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3241_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3241", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 905.45, "gross_charge": 1393.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3243_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3243", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10.06, "gross_charge": 15.47, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3246_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3246", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12.66, "gross_charge": 19.47, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3260_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3260", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12.94, "gross_charge": 19.91, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3262_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3262", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 13.46, "gross_charge": 20.71, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3285_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3285", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 143.84, "gross_charge": 221.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3301_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3301", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.32, "gross_charge": 9.73, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3357_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3357", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.01, "gross_charge": 0.01, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3358_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3358", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 52.58, "gross_charge": 80.9, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3360_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3360", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 49.87, "gross_charge": 76.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3370_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3370", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.74, "gross_charge": 30.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3371_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3371", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28.18, "gross_charge": 43.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3372_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3372", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 29.1, "gross_charge": 44.77, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3380_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3380", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 91.33, "gross_charge": 140.51, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3410_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3410", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 48.45, "gross_charge": 74.54, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3411_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3411", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.76, "gross_charge": 22.71, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3415_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3415", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 39.16, "gross_charge": 60.24, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3420_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3420", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 27.22, "gross_charge": 41.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3424_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3424", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3124.58, "gross_charge": 4807.05, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3430_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3430", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 49.63, "gross_charge": 76.36, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3465_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3465", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.28, "gross_charge": 8.12, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3473_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3473", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.03, "gross_charge": 1.58, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3475_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3475", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.69, "gross_charge": 10.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3480_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.45, "gross_charge": 6.85, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3486_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3486", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 38.63, "gross_charge": 59.43, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3489_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3489", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 26.48, "gross_charge": 40.74, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3490_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9.94, "gross_charge": 15.3, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J3590_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3590", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 82.07, "gross_charge": 126.26, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7060_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7060", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 43.86, "gross_charge": 67.47, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7070_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7070", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 45.02, "gross_charge": 69.26, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7120_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7120", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 44.91, "gross_charge": 69.09, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7131_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7131", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.12, "gross_charge": 0.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7168_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7168", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.71, "gross_charge": 8.79, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7187_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7187", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.89, "gross_charge": 4.45, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7189_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7189", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.38, "gross_charge": 11.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7192_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7192", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.03, "gross_charge": 6.2, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7195_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7195", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.26, "gross_charge": 8.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7197_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7197", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.85, "gross_charge": 18.23, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7296_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7296", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2190.92, "gross_charge": 3370.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7297_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7297", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1790.04, "gross_charge": 2753.9, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7298_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7298", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2251.39, "gross_charge": 3463.67, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7298_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7298", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2211.31, "gross_charge": 3402.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7300_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7300", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2147.65, "gross_charge": 3304.08, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7301_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7301", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1824.86, "gross_charge": 2807.48, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7307_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7307", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2138.64, "gross_charge": 3290.22, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7504_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7504", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 12689.9, "gross_charge": 19522.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7511_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7511", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3570.64, "gross_charge": 5493.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7516_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7516", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 92.62, "gross_charge": 142.49, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7519_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7519", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.41, "gross_charge": 2.17, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7525_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7525", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 286.86, "gross_charge": 441.33, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7674_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.72, "gross_charge": 2.65, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J7999_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 71.38, "gross_charge": 109.82, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9000_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9000", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 20.47, "gross_charge": 31.49, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9017_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9017", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18.92, "gross_charge": 29.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9022_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9022", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 232.89, "gross_charge": 358.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9023_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9023", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 264.32, "gross_charge": 406.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9025_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9025", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.36, "gross_charge": 2.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9030_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9030", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9.59, "gross_charge": 14.75, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9034_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9034", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 49.3, "gross_charge": 75.84, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9035_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9035", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 217.56, "gross_charge": 334.71, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9039_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9039", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 411.43, "gross_charge": 632.97, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9040_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9040", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 75.46, "gross_charge": 116.09, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9041_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9041", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.33, "gross_charge": 8.2, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9042_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9042", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 561.66, "gross_charge": 864.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9043_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9043", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 612.33, "gross_charge": 942.05, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9045_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9045", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.07, "gross_charge": 21.65, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9047_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9047", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 119.13, "gross_charge": 183.27, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9050_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9050", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 606.14, "gross_charge": 932.52, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9055_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9055", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 198.31, "gross_charge": 305.09, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9060_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9060", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 15.8, "gross_charge": 24.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9063_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9063", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 177.92, "gross_charge": 273.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9065_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9065", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 33.9, "gross_charge": 52.15, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9070_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9070", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 88.5, "gross_charge": 136.16, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9071_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9071", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.87, "gross_charge": 2.87, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9073_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9073", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.15, "gross_charge": 6.38, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9075_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9075", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.37, "gross_charge": 3.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9100_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9100", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.01, "gross_charge": 6.17, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9119_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9119", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 81.22, "gross_charge": 124.95, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9120_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9120", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3912.32, "gross_charge": 6018.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9130_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9130", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 22.11, "gross_charge": 34.01, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9144_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9144", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 143.06, "gross_charge": 220.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9145_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9145", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 192.4, "gross_charge": 296.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9150_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9150", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 78.8, "gross_charge": 121.23, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9153_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9153", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 620.08, "gross_charge": 953.97, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9155_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9155", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 16.9, "gross_charge": 26.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9171_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9171", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.03, "gross_charge": 6.2, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9173_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9173", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 229.35, "gross_charge": 352.85, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9177_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9177", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 97.82, "gross_charge": 150.49, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9179_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9179", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 399.88, "gross_charge": 615.2, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9181_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9181", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.51, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9185_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9185", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2250.22, "gross_charge": 3461.87, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9190_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9190", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17.11, "gross_charge": 26.32, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9201_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9201", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.84, "gross_charge": 22.83, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9202_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9202", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2674.87, "gross_charge": 4115.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9203_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9203", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 611.17, "gross_charge": 940.26, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9204_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9204", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 578.7, "gross_charge": 890.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9205_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9205", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 175.28, "gross_charge": 269.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9206_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9206", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.93, "gross_charge": 18.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9208_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9208", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 83.15, "gross_charge": 127.92, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9209_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9209", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.57, "gross_charge": 22.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9217_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 427.69, "gross_charge": 657.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9223_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9223", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 558.71, "gross_charge": 859.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9227_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9227", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 153.09, "gross_charge": 235.52, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9228_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9228", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 452.72, "gross_charge": 696.49, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9245_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9245", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 251.08, "gross_charge": 386.28, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9250_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9250", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.73, "gross_charge": 8.82, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9255_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9255", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.46, "gross_charge": 9.94, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9259_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9259", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 38.95, "gross_charge": 59.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9260_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9260", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.8, "gross_charge": 5.85, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9261_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9261", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 154.29, "gross_charge": 237.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9263_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9263", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.46, "gross_charge": 0.7, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9264_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9264", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 42.72, "gross_charge": 65.72, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9266_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9266", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 55154.39, "gross_charge": 84852.91, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9267_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9267", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.69, "gross_charge": 1.06, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9271_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9271", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 150.17, "gross_charge": 231.03, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9272_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9272", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 636.96, "gross_charge": 979.94, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9273_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9273", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 467.04, "gross_charge": 718.52, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9280_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9280", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 91.34, "gross_charge": 140.53, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9281_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9281", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 829.18, "gross_charge": 1275.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9294_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9294", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.39, "gross_charge": 6.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9296_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9296", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.34, "gross_charge": 17.45, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9299_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9299", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 85.06, "gross_charge": 130.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9301_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9301", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 228.62, "gross_charge": 351.73, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9303_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9303", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 437.24, "gross_charge": 672.67, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9305_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9305", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9306_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9306", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 38.51, "gross_charge": 59.25, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9307_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9307", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1001.42, "gross_charge": 1540.65, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9308_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9308", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 201.12, "gross_charge": 309.42, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9309_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9309", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 108.56, "gross_charge": 167.01, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9311_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9311", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 108.34, "gross_charge": 166.67, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9312_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9312", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 246.84, "gross_charge": 379.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9316_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9316", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 204.02, "gross_charge": 313.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9317_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9317", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 93.37, "gross_charge": 143.65, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9323_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9323", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.1, "gross_charge": 6.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9332_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9332", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 101.28, "gross_charge": 155.81, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9333_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9333", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 72.9, "gross_charge": 112.16, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9334_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9334", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 105.61, "gross_charge": 162.47, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9340_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9340", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1463.34, "gross_charge": 2251.3, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9347_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9347", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 354.19, "gross_charge": 544.91, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9349_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9349", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 37.39, "gross_charge": 57.53, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9351_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9351", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 20.9, "gross_charge": 32.15, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9352_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9352", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 958.42, "gross_charge": 1474.5, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9354_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9354", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 109.17, "gross_charge": 167.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9355_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9355", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 291.39, "gross_charge": 448.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9356_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9356", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 217.32, "gross_charge": 334.34, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9358_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9358", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 74.09, "gross_charge": 113.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9360_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9360", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18.3, "gross_charge": 28.15, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9370_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9370", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 51.66, "gross_charge": 79.48, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9390_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9390", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 32.39, "gross_charge": 49.83, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_J9395_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9395", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17.24, "gross_charge": 26.53, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_P9045_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "P9045", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 121.95, "gross_charge": 187.61, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_P9047_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "P9047", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 111.83, "gross_charge": 172.04, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q0138_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q0138", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.9, "gross_charge": 2.93, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q0249_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q0249", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18.2, "gross_charge": 28.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q2004_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q2004", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 55.2, "gross_charge": 84.92, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q2009_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q2009", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.25, "gross_charge": 11.16, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q2050_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q2050", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 422.29, "gross_charge": 649.68, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q4081_634", "type": "CDM" }, { "code": "634", "type": "RC" }, { "code": "Q4081", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.45, "gross_charge": 6.85, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q4081_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q4081", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.82, "gross_charge": 7.42, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q4801_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q4801", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.59, "gross_charge": 10.14, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5101_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5101", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.3, "gross_charge": 3.54, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5103_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5103", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 182.53, "gross_charge": 280.82, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5104_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5104", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 99.34, "gross_charge": 152.83, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5105_635", "type": "CDM" }, { "code": "635", "type": "RC" }, { "code": "Q5105", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5105_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5105", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.11, "gross_charge": 4.78, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5106_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5106", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5107_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5107", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 178.71, "gross_charge": 274.94, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5108_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5108", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 392.94, "gross_charge": 604.53, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5110_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5110", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.0, "gross_charge": 1.54, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5111_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5111", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 698.67, "gross_charge": 1074.87, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5112_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5112", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 105.88, "gross_charge": 162.89, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5113_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5113", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 257.69, "gross_charge": 396.44, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5115_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5115", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 167.25, "gross_charge": 257.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5117_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5117", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 245.27, "gross_charge": 377.34, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5118_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5118", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 149.64, "gross_charge": 230.22, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5119_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5119", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 159.17, "gross_charge": 244.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5120_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5120", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1013.31, "gross_charge": 1558.94, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5121_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5121", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 161.95, "gross_charge": 249.16, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5122_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5122", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 59.58, "gross_charge": 91.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5123_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5123", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 157.94, "gross_charge": 242.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q5130_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5130", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 626.78, "gross_charge": 964.28, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q9957_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9957", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 80.75, "gross_charge": 124.23, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_Q9968_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9968", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 35.49, "gross_charge": 54.6, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_S0028_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "S0028", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 24.39, "gross_charge": 37.53, "setting": "both" } ] }, { "code_information": [ { "code": "63600006_S0074_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "S0074", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 21.44, "gross_charge": 32.98, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_636", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.29, "gross_charge": 0.44, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_A9575_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "A9575", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.29, "gross_charge": 0.44, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_A9577_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "A9577", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.94, "gross_charge": 7.6, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_A9579_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "A9579", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.14, "gross_charge": 9.45, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_A9581_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "A9581", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 45.35, "gross_charge": 69.77, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_Q9958_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9958", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.16, "gross_charge": 0.25, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_Q9965_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9965", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 15.35, "gross_charge": 23.61, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_Q9966_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9966", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.94, "gross_charge": 1.45, "setting": "both" } ] }, { "code_information": [ { "code": "63600007_Q9967_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9967", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.35, "gross_charge": 0.54, "setting": "both" } ] }, { "code_information": [ { "code": "63600011", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4125", "type": "HCPCS" } ], "description": "Hc Arthroflex Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 726.74, "gross_charge": 1118.06, "setting": "both" } ] }, { "code_information": [ { "code": "63600014", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4186", "type": "HCPCS" } ], "description": "Hc Epifix 2X3 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 406.64, "gross_charge": 625.6, "setting": "both" } ] }, { "code_information": [ { "code": "63600015", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4186", "type": "HCPCS" } ], "description": "Hc Epifix 1.4 Per Sq Cm Disk", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 476.52, "gross_charge": 733.11, "setting": "both" } ] }, { "code_information": [ { "code": "63600017", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4186", "type": "HCPCS" } ], "description": "Hc Epifix 2X2 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 567.03, "gross_charge": 872.36, "setting": "both" } ] }, { "code_information": [ { "code": "63600018", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4186", "type": "HCPCS" } ], "description": "Hc Epifix 2X4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 359.39, "gross_charge": 552.91, "setting": "both" } ] }, { "code_information": [ { "code": "63600019", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4186", "type": "HCPCS" } ], "description": "Hc Epifix 3X4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 422.62, "gross_charge": 650.18, "setting": "both" } ] }, { "code_information": [ { "code": "63600020", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4186", "type": "HCPCS" } ], "description": "Hc Epifix 4X4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 406.64, "gross_charge": 625.6, "setting": "both" } ] }, { "code_information": [ { "code": "63600021", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4186", "type": "HCPCS" } ], "description": "Hc Epifix 4X4.5 Mesh Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 164.38, "gross_charge": 252.9, "setting": "both" } ] }, { "code_information": [ { "code": "63600025", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4126", "type": "HCPCS" } ], "description": "Hc Dermaspan Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 221.05, "gross_charge": 340.07, "setting": "both" } ] }, { "code_information": [ { "code": "63600028", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafix Or Stravix Prime Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 643.56, "gross_charge": 990.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600030", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4121", "type": "HCPCS" } ], "description": "Hc Theraskin 39 Sq Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 71.21, "gross_charge": 109.56, "setting": "both" } ] }, { "code_information": [ { "code": "63600031", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4121", "type": "HCPCS" } ], "description": "Hc Theraskin 13 Sq Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 145.09, "gross_charge": 223.21, "setting": "both" } ] }, { "code_information": [ { "code": "63600032", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 183.03, "gross_charge": 281.58, "setting": "both" } ] }, { "code_information": [ { "code": "63600033", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial 2X2/Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 394.26, "gross_charge": 606.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600034", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial 2X4/Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 252.57, "gross_charge": 388.57, "setting": "both" } ] }, { "code_information": [ { "code": "63600035", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial 5X5/Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 234.27, "gross_charge": 360.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600036", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial 6X9/Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 234.27, "gross_charge": 360.41, "setting": "both" } ] }, { "code_information": [ { "code": "63600038", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4148", "type": "HCPCS" } ], "description": "Hc Neox Or Clarix Cord, Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 227.06, "gross_charge": 349.32, "setting": "both" } ] }, { "code_information": [ { "code": "63600041", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4166", "type": "HCPCS" } ], "description": "Hc Cytal Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 68.43, "gross_charge": 105.27, "setting": "both" } ] }, { "code_information": [ { "code": "63600042", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4150", "type": "HCPCS" } ], "description": "Hc Allowrap Ds Or Dry Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 554.28, "gross_charge": 852.74, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90619_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90619", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 408.94, "gross_charge": 629.14, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90620_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90620", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 695.25, "gross_charge": 1069.62, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90632_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90632", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 244.26, "gross_charge": 375.78, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90633_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90633", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 101.38, "gross_charge": 155.97, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90648_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90648", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 60.68, "gross_charge": 93.35, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90656_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90656", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 72.03, "gross_charge": 110.81, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90662_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90662", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 210.48, "gross_charge": 323.81, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90675_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90675", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 951.4, "gross_charge": 1463.69, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90677_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90677", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 812.27, "gross_charge": 1249.64, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90686_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90686", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 79.28, "gross_charge": 121.97, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90707_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90707", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 302.16, "gross_charge": 464.86, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90714_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90714", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 135.46, "gross_charge": 208.4, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90715_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90715", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 148.06, "gross_charge": 227.79, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90716_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90716", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 559.32, "gross_charge": 860.5, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90732_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90732", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 394.41, "gross_charge": 606.78, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90744_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90744", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.67, "gross_charge": 1.03, "setting": "both" } ] }, { "code_information": [ { "code": "63600043_90750_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90750", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 552.09, "gross_charge": 849.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600044", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafix Prime 16Mm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 644.4, "gross_charge": 991.39, "setting": "both" } ] }, { "code_information": [ { "code": "63600045", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafix Prime 1.5 X 2 Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 593.66, "gross_charge": 913.32, "setting": "both" } ] }, { "code_information": [ { "code": "63600046", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafix Prime 2 X 3 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 364.49, "gross_charge": 560.76, "setting": "both" } ] }, { "code_information": [ { "code": "63600047", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafix Prime 3 X 4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 221.62, "gross_charge": 340.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600048", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4133", "type": "HCPCS" } ], "description": "Hc Grafix Prime 5 X 5 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 232.93, "gross_charge": 358.36, "setting": "both" } ] }, { "code_information": [ { "code": "63600049", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4132", "type": "HCPCS" } ], "description": "Hc Grafix Core 16Mm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 658.88, "gross_charge": 1013.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600050", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4132", "type": "HCPCS" } ], "description": "Hc Grafix Core 1.5 X 2 Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 593.66, "gross_charge": 913.32, "setting": "both" } ] }, { "code_information": [ { "code": "63600051", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4132", "type": "HCPCS" } ], "description": "Hc Grafix Core 2 X 3 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 372.03, "gross_charge": 572.36, "setting": "both" } ] }, { "code_information": [ { "code": "63600052", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4132", "type": "HCPCS" } ], "description": "Hc Grafix Core 3 X 4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 228.28, "gross_charge": 351.2, "setting": "both" } ] }, { "code_information": [ { "code": "63600053", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4132", "type": "HCPCS" } ], "description": "Hc Grafix Core 5 X 5 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 232.93, "gross_charge": 358.36, "setting": "both" } ] }, { "code_information": [ { "code": "63600054", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4152", "type": "HCPCS" } ], "description": "Hc Dermapure Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4891.68, "gross_charge": 7525.66, "setting": "both" } ] }, { "code_information": [ { "code": "63600058", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4196", "type": "HCPCS" } ], "description": "Hc Puraply Antimicrobial 1.6Cm Disc Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 595.15, "gross_charge": 915.62, "setting": "both" } ] }, { "code_information": [ { "code": "63600059", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4159", "type": "HCPCS" } ], "description": "Hc Affinity 2.25Cm Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 353.4, "gross_charge": 543.69, "setting": "both" } ] }, { "code_information": [ { "code": "63600060", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4159", "type": "HCPCS" } ], "description": "Hc Affinity 6.25 Cm Pr Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 698.82, "gross_charge": 1075.1, "setting": "both" } ] }, { "code_information": [ { "code": "63600061", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4160", "type": "HCPCS" } ], "description": "Hc Nushield 1.6 Sq Cm Disc Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 526.44, "gross_charge": 809.9, "setting": "both" } ] }, { "code_information": [ { "code": "63600062", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4160", "type": "HCPCS" } ], "description": "Hc Nushield 2X3 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 280.69, "gross_charge": 431.83, "setting": "both" } ] }, { "code_information": [ { "code": "63600063", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4160", "type": "HCPCS" } ], "description": "Hc Nushield 2X4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 251.08, "gross_charge": 386.27, "setting": "both" } ] }, { "code_information": [ { "code": "63600064", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4160", "type": "HCPCS" } ], "description": "Hc Nushield 3X4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 241.59, "gross_charge": 371.68, "setting": "both" } ] }, { "code_information": [ { "code": "63600065", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4160", "type": "HCPCS" } ], "description": "Hc Nushield 4X4 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 248.24, "gross_charge": 381.91, "setting": "both" } ] }, { "code_information": [ { "code": "63600066", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4160", "type": "HCPCS" } ], "description": "Hc Nushield 4X6 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 230.94, "gross_charge": 355.29, "setting": "both" } ] }, { "code_information": [ { "code": "63600067", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4160", "type": "HCPCS" } ], "description": "Hc Nushield 6X6 Per Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 210.31, "gross_charge": 323.55, "setting": "both" } ] }, { "code_information": [ { "code": "63600068", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4178", "type": "HCPCS" } ], "description": "Hc Floweramniopatch Amniotic Membrane", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 268.24, "gross_charge": 412.68, "setting": "both" } ] }, { "code_information": [ { "code": "63600069", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "Q4177", "type": "HCPCS" } ], "description": "Hc Floweramnioflo", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5885.99, "gross_charge": 9055.37, "setting": "both" } ] }, { "code_information": [ { "code": "63600080", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90651", "type": "HCPCS" } ], "description": "Hc Hpv Vaccine 9 Valent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 494.83, "gross_charge": 761.28, "setting": "both" } ] }, { "code_information": [ { "code": "63600081", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90651", "type": "HCPCS" } ], "description": "Hc Grant Funded Hpv Vaccine 9 Valent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 494.83, "gross_charge": 761.28, "setting": "both" } ] }, { "code_information": [ { "code": "63600082", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Cablivi Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1984.31, "gross_charge": 3052.79, "setting": "both" } ] }, { "code_information": [ { "code": "63600083", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Remdesivir Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 19.8, "gross_charge": 30.46, "setting": "both" } ] }, { "code_information": [ { "code": "63600084", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Tecentriq Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 228.72, "gross_charge": 351.88, "setting": "both" } ] }, { "code_information": [ { "code": "63600085", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Imfinzi Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 220.86, "gross_charge": 339.78, "setting": "both" } ] }, { "code_information": [ { "code": "63600086", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Soliris Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 567.63, "gross_charge": 873.28, "setting": "both" } ] }, { "code_information": [ { "code": "63600087", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Zerbaxa Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 25.97, "gross_charge": 39.96, "setting": "both" } ] }, { "code_information": [ { "code": "63600088", "type": "CDM" }, { "code": "278", "type": "RC" }, { "code": "C2625", "type": "HCPCS" } ], "description": "Hc Mometasone Furoate Propel Implant 370 Mcgs Per 10 Mcg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2195.12, "gross_charge": 3377.11, "setting": "both" } ] }, { "code_information": [ { "code": "63600089", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9966", "type": "HCPCS" } ], "description": "Hc Isovue-M 200 299 Mg Per Ml Iodine Per Ml", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2.7, "gross_charge": 4.16, "setting": "both" } ] }, { "code_information": [ { "code": "63600090", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "M1145", "type": "HCPCS" } ], "description": "Hc Mfn Add On", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 227.14, "gross_charge": 349.44, "setting": "both" } ] }, { "code_information": [ { "code": "63600092", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "M0245", "type": "HCPCS" } ], "description": "Hc Covid-19 Antibody Bamlanivimab & Entesevimab Infusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 604.5, "gross_charge": 930.0, "setting": "both" } ] }, { "code_information": [ { "code": "63600093", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Fetroja Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.16, "gross_charge": 11.02, "setting": "both" } ] }, { "code_information": [ { "code": "63600095", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Rybrevant Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 56.6, "gross_charge": 87.08, "setting": "both" } ] }, { "code_information": [ { "code": "63600099", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Darzalex Faspro Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 134.75, "gross_charge": 207.31, "setting": "both" } ] }, { "code_information": [ { "code": "63600103", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Columvi Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7296.37, "gross_charge": 11225.19, "setting": "both" } ] }, { "code_information": [ { "code": "63600105", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Spevigo Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 157.87, "gross_charge": 242.87, "setting": "both" } ] }, { "code_information": [ { "code": "63600106", "type": "CDM" }, { "code": "636", "type": "RC" } ], "description": "Hc Rx Oh Tecvayli Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 87.92, "gross_charge": 135.26, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_250", "type": "CDM" }, { "code": "250", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.78, "gross_charge": 5.82, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_637", "type": "CDM" }, { "code": "637", "type": "RC" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.93, "gross_charge": 6.05, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J0571_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J0571", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 9.54, "gross_charge": 14.67, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J0571_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0571", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.36, "gross_charge": 6.7, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J0572_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J0572", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.15, "gross_charge": 12.54, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J0572_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0572", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.97, "gross_charge": 12.26, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J0574_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J0574", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 13.27, "gross_charge": 20.42, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J0574_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0574", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 13.45, "gross_charge": 20.69, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J1815_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J1815", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.29, "gross_charge": 9.68, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J1815_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.87, "gross_charge": 9.03, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2212_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J2212", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.42, "gross_charge": 6.8, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2212_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2212", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.38, "gross_charge": 6.74, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2212_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2212", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.44, "gross_charge": 6.83, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2354_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J2354", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.86, "gross_charge": 5.94, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2354_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2354", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.55, "gross_charge": 11.61, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2354_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2354", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.43, "gross_charge": 5.27, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2440_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J2440", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 72.13, "gross_charge": 110.97, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J2440_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2440", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 69.97, "gross_charge": 107.65, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J3030_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J3030", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 37.98, "gross_charge": 58.43, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J3030_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3030", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 36.61, "gross_charge": 56.32, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J3490_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3490", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.97, "gross_charge": 3.03, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J3535_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J3535", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.2, "gross_charge": 3.38, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J3535_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3535", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.08, "gross_charge": 1.66, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J3535_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3535", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.96, "gross_charge": 3.02, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7500_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7500", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.19, "gross_charge": 4.91, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7500_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7500", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.91, "gross_charge": 4.47, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7502_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7502", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 10.98, "gross_charge": 16.89, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7502_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7502", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.99, "gross_charge": 7.67, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7503_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7503", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.04, "gross_charge": 4.67, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7503_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7503", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.98, "gross_charge": 4.58, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7507_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7507", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.76, "gross_charge": 5.78, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7507_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7507", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.24, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7509_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7509", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.3, "gross_charge": 5.07, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7509_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7509", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.96, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7510_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7510", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.47, "gross_charge": 2.26, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7510_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7510", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.49, "gross_charge": 2.29, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7512_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7512", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.16, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7512_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.08, "gross_charge": 0.13, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7515_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7515", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.3, "gross_charge": 3.54, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7515_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7515", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.01, "gross_charge": 4.63, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7517_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7517", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.86, "gross_charge": 4.4, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7517_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7517", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 2.68, "gross_charge": 4.12, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7518_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7518", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 7.63, "gross_charge": 11.74, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7518_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7518", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 8.16, "gross_charge": 12.56, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7520_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7520", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 17.13, "gross_charge": 26.36, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7520_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7520", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 14.51, "gross_charge": 22.32, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7527_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7527", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 11.84, "gross_charge": 18.21, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J7527_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7527", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 13.7, "gross_charge": 21.08, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8501_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J8501", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18.62, "gross_charge": 28.64, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8501_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8501", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 18.52, "gross_charge": 28.49, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8515_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J8515", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.43, "gross_charge": 5.28, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8515_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8515", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.69, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8530_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J8530", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 5.62, "gross_charge": 8.64, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8530_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8530", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 6.17, "gross_charge": 9.49, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8540_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J8540", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.22, "gross_charge": 0.34, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8540_636", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J8540", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8540_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8540", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 0.2, "gross_charge": 0.3, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8610_250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J8610", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.82, "gross_charge": 7.41, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_J8610_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8610", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 4.54, "gross_charge": 6.98, "setting": "both" } ] }, { "code_information": [ { "code": "63700001_Q0144_637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "Q0144", "type": "HCPCS" } ], "description": "Noncdm Charge Record Pharmacy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 49.09, "gross_charge": 75.52, "setting": "both" } ] }, { "code_information": [ { "code": "63700003", "type": "CDM" }, { "code": "637", "type": "RC" } ], "description": "Hc Rx Insulin Lispro", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.03, "gross_charge": 1.58, "setting": "both" } ] }, { "code_information": [ { "code": "63700004", "type": "CDM" }, { "code": "637", "type": "RC" } ], "description": "Hc Rx Oh Baricitinib Ntap", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 179.84, "gross_charge": 276.68, "setting": "both" } ] }, { "code_information": [ { "code": "63700006", "type": "CDM" }, { "code": "637", "type": "RC" } ], "description": "Hc Rx Insulin Glargine Pen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1.32, "gross_charge": 2.03, "setting": "both" } ] }, { "code_information": [ { "code": "68100001", "type": "CDM" }, { "code": "681", "type": "RC" }, { "code": "G0390", "type": "HCPCS" } ], "description": "Hc Trauma Activation Cat 1 Level 1 Grant Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12697.75, "gross_charge": 19535.0, "setting": "both" } ] }, { "code_information": [ { "code": "68100002", "type": "CDM" }, { "code": "681", "type": "RC" }, { "code": "G0390", "type": "HCPCS" } ], "description": "Hc Trauma Activation Cat 2 Level 1 Grant Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10159.5, "gross_charge": 15630.0, "setting": "both" } ] }, { "code_information": [ { "code": "68200001", "type": "CDM" }, { "code": "682", "type": "RC" }, { "code": "G0390", "type": "HCPCS" } ], "description": "Hc Trauma Activation Fee Cat 1 Lev 2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 12697.75, "gross_charge": 19535.0, "setting": "both" } ] }, { "code_information": [ { "code": "68200002", "type": "CDM" }, { "code": "682", "type": "RC" }, { "code": "G0390", "type": "HCPCS" } ], "description": "Hc Trauma Activation Fee Cat 2 Lev 2", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 10159.5, "gross_charge": 15630.0, "setting": "both" } ] }, { "code_information": [ { "code": "68300001", "type": "CDM" }, { "code": "683", "type": "RC" }, { "code": "G0390", "type": "HCPCS" } ], "description": "Hc Trauma Activation Fee Cat 1 Lev 3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7230.6, "gross_charge": 11124.0, "setting": "both" } ] }, { "code_information": [ { "code": "68300002", "type": "CDM" }, { "code": "683", "type": "RC" }, { "code": "G0390", "type": "HCPCS" } ], "description": "Hc Trauma Activation Fee Cat2 Lev 3", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5623.8, "gross_charge": 8652.0, "setting": "both" } ] }, { "code_information": [ { "code": "71000001", "type": "CDM" }, { "code": "710", "type": "RC" } ], "description": "Hc Pacu 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 740.35, "gross_charge": 1139.0, "setting": "both" } ] }, { "code_information": [ { "code": "71000002", "type": "CDM" }, { "code": "710", "type": "RC" } ], "description": "Hc Pacu Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 289.25, "gross_charge": 445.0, "setting": "both" } ] }, { "code_information": [ { "code": "71000004", "type": "CDM" }, { "code": "710", "type": "RC" } ], "description": "Hc Pacu L And D 1St Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1176.5, "gross_charge": 1810.0, "setting": "both" } ] }, { "code_information": [ { "code": "71000005", "type": "CDM" }, { "code": "710", "type": "RC" } ], "description": "Hc Pacu L And D Addl 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 501.8, "gross_charge": 772.0, "setting": "both" } ] }, { "code_information": [ { "code": "71000006", "type": "CDM" }, { "code": "710", "type": "RC" } ], "description": "Hc Pacu Stage 2 1St 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 740.35, "gross_charge": 1139.0, "setting": "both" } ] }, { "code_information": [ { "code": "71000007", "type": "CDM" }, { "code": "710", "type": "RC" } ], "description": "Hc Pacu Stage 2 Addl 15 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 289.25, "gross_charge": 445.0, "setting": "both" } ] }, { "code_information": [ { "code": "72000001", "type": "CDM" }, { "code": "720", "type": "RC" }, { "code": "59414", "type": "HCPCS" } ], "description": "Hc Delivery Placenta (Separate Proc)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1439.75, "gross_charge": 2215.0, "setting": "both" } ] }, { "code_information": [ { "code": "72000003", "type": "CDM" }, { "code": "720", "type": "RC" }, { "code": "99465", "type": "HCPCS" } ], "description": "Hc Newborn Resuscitation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1597.7, "gross_charge": 2458.0, "setting": "both" } ] }, { "code_information": [ { "code": "72200001", "type": "CDM" }, { "code": "722", "type": "RC" } ], "description": "Hc Delivery Cesarean", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5288.4, "gross_charge": 8136.0, "setting": "both" } ] }, { "code_information": [ { "code": "72200004", "type": "CDM" }, { "code": "722", "type": "RC" } ], "description": "Hc Delivery Vaginal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4813.25, "gross_charge": 7405.0, "setting": "both" } ] }, { "code_information": [ { "code": "73000001", "type": "CDM" }, { "code": "730", "type": "RC" }, { "code": "93005", "type": "HCPCS" } ], "description": "Hc Ekg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 99.45, "gross_charge": 153.0, "setting": "both" } ] }, { "code_information": [ { "code": "73000002", "type": "CDM" }, { "code": "730", "type": "RC" }, { "code": "93041", "type": "HCPCS" } ], "description": "Hc Ekg Rhythm Tracing Only", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 220.35, "gross_charge": 339.0, "setting": "both" } ] }, { "code_information": [ { "code": "73000003", "type": "CDM" }, { "code": "730", "type": "RC" }, { "code": "0897T", "type": "HCPCS" } ], "description": "Hc N-Invas Augmnt Arrhyt Alys Quan Card Arrhyt Simul", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2202.2, "gross_charge": 3388.0, "setting": "both" } ] }, { "code_information": [ { "code": "73100001", "type": "CDM" }, { "code": "731", "type": "RC" }, { "code": "93225", "type": "HCPCS" } ], "description": "Hc Holter Scan Recording Up To 48 Hr", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 375.05, "gross_charge": 577.0, "setting": "both" } ] }, { "code_information": [ { "code": "73100002", "type": "CDM" }, { "code": "731", "type": "RC" }, { "code": "93270", "type": "HCPCS" } ], "description": "Hc Event Recording", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 375.05, "gross_charge": 577.0, "setting": "both" } ] }, { "code_information": [ { "code": "73100003", "type": "CDM" }, { "code": "731", "type": "RC" }, { "code": "93278", "type": "HCPCS" } ], "description": "Hc Ekg Signal Averaged", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 538.85, "gross_charge": 829.0, "setting": "both" } ] }, { "code_information": [ { "code": "73100007", "type": "CDM" }, { "code": "731", "type": "RC" }, { "code": "93242", "type": "HCPCS" } ], "description": "Hc Holter Recording 49 Hrs Up To 7 Days", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 375.05, "gross_charge": 577.0, "setting": "both" } ] }, { "code_information": [ { "code": "73100009", "type": "CDM" }, { "code": "731", "type": "RC" }, { "code": "93246", "type": "HCPCS" } ], "description": "Hc Holter Recording 8 Days Up To 15 Days", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 375.05, "gross_charge": 577.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000001", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95812", "type": "HCPCS" } ], "description": "Hc Eeg Monitor 41-60 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1062.1, "gross_charge": 1634.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000002", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95813", "type": "HCPCS" } ], "description": "Hc Eeg Monitor 61 To 119 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1062.1, "gross_charge": 1634.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000003", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95816", "type": "HCPCS" } ], "description": "Hc Eeg Awake And Drowsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1062.1, "gross_charge": 1634.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000004", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95819", "type": "HCPCS" } ], "description": "Hc Eeg Awake And Asleep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1062.1, "gross_charge": 1634.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000005", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95822", "type": "HCPCS" } ], "description": "Hc Eeg Coma Or Sleep", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1062.1, "gross_charge": 1634.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000006", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95824", "type": "HCPCS" } ], "description": "Hc Eeg Cerebral Death", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2028.0, "gross_charge": 3120.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000007", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95829", "type": "HCPCS" } ], "description": "Hc Electrocorticogram At Surgery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 7346.95, "gross_charge": 11303.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000012", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95957", "type": "HCPCS" } ], "description": "Hc Eeg Analysis Digital", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 174.85, "gross_charge": 269.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000013", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95958", "type": "HCPCS" } ], "description": "Hc Eeg Hemisphere Function Wada", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 644.15, "gross_charge": 991.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000014", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95961", "type": "HCPCS" } ], "description": "Hc Functional Mapping Stimulation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4395.3, "gross_charge": 6762.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000023", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95700", "type": "HCPCS" } ], "description": "Hc Lt Eeg Tech Setup", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1766.05, "gross_charge": 2717.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000030", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95711", "type": "HCPCS" } ], "description": "Hc Veeg Lt Unmonitored 2-12 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2808.0, "gross_charge": 4320.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000031", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95712", "type": "HCPCS" } ], "description": "Hc Veeg Lt Intermittent 2-12 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2808.0, "gross_charge": 4320.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000032", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95713", "type": "HCPCS" } ], "description": "Hc Veeg Lt Continuous 2-12 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2808.0, "gross_charge": 4320.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000033", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95714", "type": "HCPCS" } ], "description": "Hc Veeg Lt Unmonitored 12-26 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4909.45, "gross_charge": 7553.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000034", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95715", "type": "HCPCS" } ], "description": "Hc Veeg Lt Intermittent 12-26 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4909.45, "gross_charge": 7553.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000035", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95716", "type": "HCPCS" } ], "description": "Hc Veeg Lt Continuous 12-26 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4909.45, "gross_charge": 7553.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000046", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95705", "type": "HCPCS" } ], "description": "Hc Ambulatory Eeg Lt Unmonitored 2-12 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2808.0, "gross_charge": 4320.0, "setting": "both" } ] }, { "code_information": [ { "code": "74000047", "type": "CDM" }, { "code": "740", "type": "RC" }, { "code": "95708", "type": "HCPCS" } ], "description": "Hc Ambulatory Eeg Lt Unmonitored 12-26 Hrs", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4909.45, "gross_charge": 7553.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000001", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43200", "type": "HCPCS" } ], "description": "Hc Esophagoscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2231.45, "gross_charge": 3433.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000002", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43201", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W Injections", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2580.5, "gross_charge": 3970.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000003", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43202", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3334.5, "gross_charge": 5130.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000004", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43204", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W/ Sclerosis Varices", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2580.5, "gross_charge": 3970.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000005", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43205", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W Band Ligation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2580.5, "gross_charge": 3970.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000006", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43215", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W Fb Removal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2390.05, "gross_charge": 3677.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000007", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43217", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W Tumor Removal Snare", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2873.65, "gross_charge": 4421.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000008", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43220", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W/ Balloon Dilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2492.75, "gross_charge": 3835.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000009", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43226", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W/ Otw Dilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2778.75, "gross_charge": 4275.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000010", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43229", "type": "HCPCS" } ], "description": "Hc Esophagoscopy W/ Tumor Ablation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2711.8, "gross_charge": 4172.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000011", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43235", "type": "HCPCS" } ], "description": "Hc Egd", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2598.7, "gross_charge": 3998.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000012", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43236", "type": "HCPCS" } ], "description": "Hc Egd W Injections", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1314.95, "gross_charge": 2023.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000013", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43237", "type": "HCPCS" } ], "description": "Hc Ugi Endo Us Limited To Esophagus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3622.45, "gross_charge": 5573.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000014", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43238", "type": "HCPCS" } ], "description": "Hc Ugi Endo Us With Fna Esophagus", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3454.1, "gross_charge": 5314.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000015", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43239", "type": "HCPCS" } ], "description": "Hc Egd W Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2738.45, "gross_charge": 4213.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000016", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43240", "type": "HCPCS" } ], "description": "Hc Egd W Drainage Pseudocyst", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4568.2, "gross_charge": 7028.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000017", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43241", "type": "HCPCS" } ], "description": "Hc Egd W Plcmnt Transendo Tube Or Cath", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2494.7, "gross_charge": 3838.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000018", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43242", "type": "HCPCS" } ], "description": "Hc Ugi Endo Us Guided Fna", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3636.1, "gross_charge": 5594.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000019", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43243", "type": "HCPCS" } ], "description": "Hc Egd W Sclerotherapy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3002.35, "gross_charge": 4619.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000020", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43244", "type": "HCPCS" } ], "description": "Hc Egd W Band Esoph Gastric Varices", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3497.0, "gross_charge": 5380.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000021", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43245", "type": "HCPCS" } ], "description": "Hc Ugi Endo Dilation Gastric Outlet Obstruction", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3216.2, "gross_charge": 4948.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000022", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43246", "type": "HCPCS" } ], "description": "Hc Egd W Peg Placement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2626.0, "gross_charge": 4040.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000023", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43247", "type": "HCPCS" } ], "description": "Hc Egd W Removal Fb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3822.65, "gross_charge": 5881.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000024", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43248", "type": "HCPCS" } ], "description": "Hc Egd W Esoph Dilation Over Guide", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3325.4, "gross_charge": 5116.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000025", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43249", "type": "HCPCS" } ], "description": "Hc Egd W Esoph Balloon Dilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3313.7, "gross_charge": 5098.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000026", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43250", "type": "HCPCS" } ], "description": "Hc Egd W/Tumor/Polyp Remove Cautery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2785.25, "gross_charge": 4285.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000027", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43251", "type": "HCPCS" } ], "description": "Hc Egd W/Tumor/Polyp Remove Snare", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3121.3, "gross_charge": 4802.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000028", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43255", "type": "HCPCS" } ], "description": "Hc Egd W/Control Of Bleeding", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3177.85, "gross_charge": 4889.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000029", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43266", "type": "HCPCS" } ], "description": "Hc Ugi Endo W/Stent Placement", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3705.0, "gross_charge": 5700.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000030", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43270", "type": "HCPCS" } ], "description": "Hc Egd W/Ablation By Laser", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2992.6, "gross_charge": 4604.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000031", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43259", "type": "HCPCS" } ], "description": "Hc Egd Endoscopic Ultrasound Exam", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3705.65, "gross_charge": 5701.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000032", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43260", "type": "HCPCS" } ], "description": "Hc Ercp", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5874.7, "gross_charge": 9038.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000033", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43261", "type": "HCPCS" } ], "description": "Hc Ercp W Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6695.0, "gross_charge": 10300.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000034", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43262", "type": "HCPCS" } ], "description": "Hc Ercp W/Sphincterotomy/Papillotomy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6875.05, "gross_charge": 10577.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000036", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43264", "type": "HCPCS" } ], "description": "Hc Ercp W/Stone Removal", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6773.0, "gross_charge": 10420.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000037", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43265", "type": "HCPCS" } ], "description": "Hc Ercp W/Lithotripsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6440.2, "gross_charge": 9908.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000038", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43274", "type": "HCPCS" } ], "description": "Hc Ercp Stent Placement Biliary/Pancreatic Duct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3910.4, "gross_charge": 6016.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000040", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43275", "type": "HCPCS" } ], "description": "Hc Ercp W Fb Remov Or Stent Biliary/Panc Duct", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6456.45, "gross_charge": 9933.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000041", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43277", "type": "HCPCS" } ], "description": "Hc Ercp W/Balloon Dilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6440.2, "gross_charge": 9908.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000043", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43273", "type": "HCPCS" } ], "description": "Hc Ercp Direct Vis/Exam Comn Bil Duc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5076.5, "gross_charge": 7810.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000044", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43450", "type": "HCPCS" } ], "description": "Hc Dilation Esoph Sound Or Bougie", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4587.05, "gross_charge": 7057.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000047", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44360", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2870.4, "gross_charge": 4416.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000048", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44361", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W Biopsy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2899.0, "gross_charge": 4460.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000049", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44363", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W Removal Fb", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3658.85, "gross_charge": 5629.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000050", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44364", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W Removal Lesion Snare", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3129.75, "gross_charge": 4815.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000051", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44365", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W Removal Lesion Cautery", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3041.35, "gross_charge": 4679.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000052", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44366", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W Control Bleeding", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3617.25, "gross_charge": 5565.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000053", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44369", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W Ablation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3087.5, "gross_charge": 4750.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000054", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44370", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W Stent Plcmnt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6104.15, "gross_charge": 9391.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000055", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44372", "type": "HCPCS" } ], "description": "Hc Small Intestine Endoscopy W J Tube Plcmnt", "standard_charges": [ { "additional_generic_notes": 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"code_information": [ { "code": "75000143", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43214", "type": "HCPCS" } ], "description": "Hc Esophagoscopy Flex W Balln Dilatn 30 Mm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2778.75, "gross_charge": 4275.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000144", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43233", "type": "HCPCS" } ], "description": "Hc Egd Esophagus Balloon Dilation 30 Mm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2827.5, "gross_charge": 4350.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000145", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43276", "type": "HCPCS" } ], "description": "Hc Ercp W Stent Exchange W Dilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3918.2, "gross_charge": 6028.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000146", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43253", "type": "HCPCS" } ], "description": "Hc Egd Flex Us Guide Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3103.1, "gross_charge": 4774.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000147", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43254", "type": "HCPCS" } ], "description": "Hc Egd Endo Mucosal Resection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3157.05, "gross_charge": 4857.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000148", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44384", "type": "HCPCS" } ], "description": "Hc Ileoscopy Stoma W Plcmnt Endoscopic Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3623.1, "gross_charge": 5574.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000149", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44402", "type": "HCPCS" } ], "description": "Hc Colonoscopy Stoma W Plcmnt Endoscopic Stent", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3646.5, "gross_charge": 5610.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000150", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44403", "type": "HCPCS" } ], "description": "Hc Colonoscpy Stoma W/ Mucosal Resection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3464.5, "gross_charge": 5330.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000151", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44404", "type": "HCPCS" } ], "description": "Hc Colonoscpy Stoma W/ Submucosal Inj", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2962.7, "gross_charge": 4558.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000152", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44405", "type": "HCPCS" } ], "description": "Hc Colonoscopy Stoma W Balloon Dilat", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3290.95, "gross_charge": 5063.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000153", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44406", "type": "HCPCS" } ], "description": "Hc Colonoscopy Thru Stoma W/ Endo Us", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3320.85, "gross_charge": 5109.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000155", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44408", "type": "HCPCS" } ], "description": "Hc Colonoscopy Stoma W Decompression", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3198.65, "gross_charge": 4921.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000156", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45346", "type": "HCPCS" } ], "description": "Hc Sigmoidoscopy Flx Ablation Tumor Or Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3314.35, "gross_charge": 5099.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000157", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45347", "type": "HCPCS" } ], "description": "Hc Sigmoidoscopy Flx W/ Endoscopic Stent Plcmnt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3314.35, "gross_charge": 5099.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000158", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45350", "type": "HCPCS" } ], "description": "Hc Sigmoidoscopy Flx W/ Band Ligation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2704.0, "gross_charge": 4160.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000159", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45388", "type": "HCPCS" } ], "description": "Hc Colonoscopy Flx Ablation Tumor Or Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3029.0, "gross_charge": 4660.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000160", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45389", "type": "HCPCS" } ], "description": "Hc Colonoscopy Flx W Encoscopic Stent Plcmnt", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3439.15, "gross_charge": 5291.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000161", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45393", "type": "HCPCS" } ], "description": "Hc Colonoscopy Flx W Decompression", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3320.85, "gross_charge": 5109.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000162", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45398", "type": "HCPCS" } ], "description": "Hc Colonoscopy Flx W Band Ligation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3049.8, "gross_charge": 4692.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000163", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45390", "type": "HCPCS" } ], "description": "Hc Colonoscopy W Mucosal Resection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3439.15, "gross_charge": 5291.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000164", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43999", "type": "HCPCS" } ], "description": "Hc Stomach Procedure Other", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5131.75, "gross_charge": 7895.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000166", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45349", "type": "HCPCS" } ], "description": "Hc Sigmoidoscopy W Mucosal Resection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3314.35, "gross_charge": 5099.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000167", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "91110", "type": "HCPCS" } ], "description": "Hc Gastrointestinal Tract Imaging Capsule Endoscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3051.75, "gross_charge": 4695.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000171", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "46930", "type": "HCPCS" } ], "description": "Hc Dest. Internal Hemorrhoid With Thermal Energy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5578.3, "gross_charge": 8582.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000172", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "43762", "type": "HCPCS" } ], "description": "Hc Replacement Of G-Tube Tube Perc Wo Img No Revision", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1664.65, "gross_charge": 2561.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000173", "type": "CDM" }, { "code": "450", "type": "RC" }, { "code": "43763", "type": "HCPCS" } ], "description": "Hc Replacement Of G-Tube Tube Perc Wo Img W Revision", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2977.0, "gross_charge": 4580.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000174", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "C9751", "type": "HCPCS" } ], "description": "Hc Bronchoscopy By Microwave Energy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13934.7, "gross_charge": 21438.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000176", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43278", "type": "HCPCS" } ], "description": "Hc Ercp Tumor/Polyp/Lesion Ablation W/Dilation&Wire", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 6773.0, "gross_charge": 10420.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000177", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "C9779", "type": "HCPCS" } ], "description": "Hc Endoscopic Submucosal Dissection Endoscopy Or Colonoscopy", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2691.0, "gross_charge": 4140.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000178", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "91113", "type": "HCPCS" } ], "description": "Hc Gi Tract Imaging Intraluminal Colon I&R", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3051.75, "gross_charge": 4695.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000179", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45391", "type": "HCPCS" } ], "description": "Hc Colonoscopy W Endoscope Us", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2962.7, "gross_charge": 4558.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000182", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "C9777", "type": "HCPCS" } ], "description": "Hc Esophageal Mucosal Integrity Test By Electrical Impedance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5287.1, "gross_charge": 8134.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000183", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43231", "type": "HCPCS" } ], "description": "Hc Esophagoscopy With Endoscopic Us Exam", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2580.5, "gross_charge": 3970.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000184", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44381", "type": "HCPCS" } ], "description": "Hc Ileoscopy Thru Stoma W Balloon Dilation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3623.1, "gross_charge": 5574.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000185", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "46270", "type": "HCPCS" } ], "description": "Hc Surg Tx Anal Fistula Subq", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3640.0, "gross_charge": 5600.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000186", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "44401", "type": "HCPCS" } ], "description": "Hc Colonoscopy Thru Stoma W/ Ablation Lesion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3290.95, "gross_charge": 5063.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000187", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "43210", "type": "HCPCS" } ], "description": "Hc Egd Esophagogastrc Fndoplsty", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 8490.95, "gross_charge": 13063.0, "setting": "both" } ] }, { "code_information": [ { "code": "75000188", "type": "CDM" }, { "code": "750", "type": "RC" }, { "code": "45399", "type": "HCPCS" } ], "description": "Hc Unlisted Procedure Colon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1236.95, "gross_charge": 1903.0, "setting": "both" } ] }, { "code_information": [ { "code": "76000001", "type": "CDM" }, { "code": "762", "type": "RC" }, { "code": "G0379", "type": "HCPCS" } ], "description": "Hc Observation Initial Assessment", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 458.9, "gross_charge": 706.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100001", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "59412", "type": "HCPCS" } ], "description": "Hc Cephalic Version", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2882.75, "gross_charge": 4435.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100002", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "95990", "type": "HCPCS" } ], "description": "Hc Refill And Maintenance Of Implanted Pump", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 989.95, "gross_charge": 1523.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100003", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "95991", "type": "HCPCS" } ], "description": "Hc Refill And Maintnce Of Implanted Pump Phys Asstd", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1579.5, "gross_charge": 2430.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100004", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96372", "type": "HCPCS" } ], "description": "Hc Injection Im/Subcutaneous", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 182.65, "gross_charge": 281.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100005", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96374", "type": "HCPCS" } ], "description": "Hc Ivp Single Or Initial Drug", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 226.85, "gross_charge": 349.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100006", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96375", "type": "HCPCS" } ], "description": "Hc Ivp Ea Addl Drug Or Substance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 207.35, "gross_charge": 319.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100007", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96376", "type": "HCPCS" } ], "description": "Hc Ivp Ea Addl Push Same Drug Or Substance", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 154.05, "gross_charge": 237.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100013", "type": "CDM" }, { "code": "260", "type": "RC" }, { "code": "96377", "type": "HCPCS" } ], "description": "Hc Application On Body Injector For Timed Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 144.95, "gross_charge": 223.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100014", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "40819", "type": "HCPCS" } ], "description": "Hc Excise Lip Or Cheek Fold Newborn (Frenulectomy)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1855.1, "gross_charge": 2854.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100015", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "28002", "type": "HCPCS" } ], "description": "Hc I And D Foot Single Bursa Space", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1851.85, "gross_charge": 2849.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100015_50", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "28002", "type": "HCPCS" } ], "description": "Hc I And D Foot Single Bursa Space", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3703.7, "gross_charge": 5698.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "76100016", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "G0127", "type": "HCPCS" } ], "description": "Hc Trim Dystrophic Nails", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 207.35, "gross_charge": 319.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100017", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "97605", "type": "HCPCS" } ], "description": "Hc Ip Wc Negative Pressure Wound Ther Up To 50 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1223.95, "gross_charge": 1883.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100018", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "97606", "type": "HCPCS" } ], "description": "Hc Ip Wc Negative Pressure Wound Ther More Than 50 Sq Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2454.4, "gross_charge": 3776.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100019", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "11622", "type": "HCPCS" } ], "description": "Hc Exc Malignant Les S N H F G 1.1-2.0Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1366.3, "gross_charge": 2102.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100020", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "11301", "type": "HCPCS" } ], "description": "Hc Shave Epidermal Dermal Lesion Trunk Arm Leg 0.6 To 1.0 Cm", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 781.3, "gross_charge": 1202.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100021", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "28003", "type": "HCPCS" } ], "description": "Hc I And D Foot Multiple Bursal Areas", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3084.9, "gross_charge": 4746.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100022", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "31238", "type": "HCPCS" } ], "description": "Hc Nasal/Sinus Endo With Control Hemorrhage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1820.0, "gross_charge": 2800.0, "setting": "both" } ] }, { "code_information": [ { "code": "76100022_50", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "31238", "type": "HCPCS" } ], "description": "Hc Nasal/Sinus Endo With Control Hemorrhage", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | The modified price is presented in the standard charge value. | Modifier 50: Bilateral Procedure", "billing_class": "facility", "discounted_cash": 3640.0, "gross_charge": 5600.0, "modifiers": "50", "setting": "both" } ] }, { "code_information": [ { "code": "76100023", "type": "CDM" }, { "code": "761", "type": "RC" }, { "code": "42800", "type": "HCPCS" } ], "description": "Hc Biopsy Oropharynx", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1855.1, "gross_charge": 2854.0, "setting": "both" } ] }, { "code_information": [ { "code": "76200007", "type": "CDM" }, { "code": "762", "type": "RC" }, { "code": "G0378", "type": "HCPCS" } ], "description": "Hc Observation Per Hour", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "76200014", "type": "CDM" }, { "code": "762", "type": "RC" }, { "code": "G0378", "type": "HCPCS" } ], "description": "Hc Observation Per Hour Bh", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.3, "gross_charge": 122.0, "setting": "both" } ] }, { "code_information": [ { "code": "76200023", "type": "CDM" }, { "code": "762", "type": "RC" }, { "code": "G0378", "type": "HCPCS" } ], "description": "Hc Observation Per Hour Carve Out", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 76.7, "gross_charge": 118.0, "setting": "both" } ] }, { "code_information": [ { "code": "76200024", "type": "CDM" }, { "code": "762", "type": "RC" }, { "code": "G0378", "type": "HCPCS" } ], "description": "Hc Bh Observation Per Hour Carve Out", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.3, "gross_charge": 122.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100001", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "90471", "type": "HCPCS" } ], "description": "Hc Admin Immun One Vaccine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 47.45, "gross_charge": 73.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100002", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "90472", "type": "HCPCS" } ], "description": "Hc Admin Immun Ea Addl Vaccine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100003", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "G0008", "type": "HCPCS" } ], "description": "Hc Admin Influenza Vaccine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100004", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "G0009", "type": "HCPCS" } ], "description": "Hc Admin Pneumococcal Vaccine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100005", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "G0010", "type": "HCPCS" } ], "description": "Hc Admin Hep B Vaccine", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100011", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "M0249", "type": "HCPCS" } ], "description": "Hc Admin Tocilizumab 1St Dose", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 877.5, "gross_charge": 1350.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100012", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "M0250", "type": "HCPCS" } ], "description": "Hc Admin Tocilizumab 2Nd Dose", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 877.5, "gross_charge": 1350.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100020", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "M0247", "type": "HCPCS" } ], "description": "Hc Covid-19 Antibody Sotrovimab Infusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 604.5, "gross_charge": 930.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100021", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "M0220", "type": "HCPCS" } ], "description": "Hc Covid-19 Mab Evusheld Im Injections (Tixagev And Cilgav)", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 292.5, "gross_charge": 450.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100022", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "M0222", "type": "HCPCS" } ], "description": "Hc Covid-19 Bebtelovimab Iv Injection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 682.5, "gross_charge": 1050.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100027", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "0124A", "type": "HCPCS" } ], "description": "Hc Vaccine Admin Pfizer Covid-19 Bivalent Omicron Booster", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "77100028", "type": "CDM" }, { "code": "771", "type": "RC" }, { "code": "0134A", "type": "HCPCS" } ], "description": "Hc Vaccine Admin Moderna Covid-19 Bivalent Omicron Booster", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 32.5, "gross_charge": 50.0, "setting": "both" } ] }, { "code_information": [ { "code": "78000001", "type": "CDM" }, { "code": "780", "type": "RC" }, { "code": "Q3014", "type": "HCPCS" } ], "description": "Hc Telehealth Originating Site", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 98.15, "gross_charge": 151.0, "setting": "both" } ] }, { "code_information": [ { "code": "80100001", "type": "CDM" }, { "code": "801", "type": "RC" }, { "code": "90935", "type": "HCPCS" } ], "description": "Hc Hemodialysis Proc Ip 1 Eval", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3568.5, "gross_charge": 5490.0, "setting": "both" } ] }, { "code_information": [ { "code": "80100002", "type": "CDM" }, { "code": "801", "type": "RC" }, { "code": "90935", "type": "HCPCS" } ], "description": "Hc Dialysis", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3568.5, "gross_charge": 5490.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500003", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38204", "type": "HCPCS" } ], "description": "Hc Mgt & Acq Allo Unrel Domestic Donor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1189.5, "gross_charge": 1830.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500004", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38204", "type": "HCPCS" } ], "description": "Hc Mgt & Acq Allo Unrel Intnl Donor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1026.19, "gross_charge": 1578.75, "setting": "both" } ] }, { "code_information": [ { "code": "81500005", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38204", "type": "HCPCS" } ], "description": "Hc Nmdp Non-Network Search Management Fee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 728.0, "gross_charge": 1120.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500006", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38204", "type": "HCPCS" } ], "description": "Hc Nmdp Formal Search Fee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 962.0, "gross_charge": 1480.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500007", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38204", "type": "HCPCS" } ], "description": "Hc Nmdp Fast Track Search Fee", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4956.25, "gross_charge": 7625.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500008", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38205", "type": "HCPCS" } ], "description": "Hc Nmdp Allo Pbsc International Product For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 35847.5, "gross_charge": 55150.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500009", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38230", "type": "HCPCS" } ], "description": "Hc Nmdp Allo Bone Marrow Harvest", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 27758.25, "gross_charge": 42705.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500010", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38205", "type": "HCPCS" } ], "description": "Hc Nmdp Allo Pbsc For Transplant Per Collect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 28518.75, "gross_charge": 43875.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500011", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38205", "type": "HCPCS" } ], "description": "Hc Nmdp Allo T-Cell For Transplant Per Collect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 13334.75, "gross_charge": 20515.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500012", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38205", "type": "HCPCS" } ], "description": "Hc Harvest Allo Pbsc For Transplant Per Collect", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2106.0, "gross_charge": 3240.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500013", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38205", "type": "HCPCS" } ], "description": "Hc Harvest Allo T-Cell For Transplant Per Collection", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 2106.0, "gross_charge": 3240.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500014", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38207", "type": "HCPCS" } ], "description": "Hc Cryopreservation & Store Allo Stem Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 965.9, "gross_charge": 1486.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500015", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38208", "type": "HCPCS" } ], "description": "Hc Thaw W/O Wash Allo Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 965.9, "gross_charge": 1486.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500016", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38209", "type": "HCPCS" } ], "description": "Hc Thaw W/Wash Allo Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1105.65, "gross_charge": 1701.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500017", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38214", "type": "HCPCS" } ], "description": "Hc Plasma Depletion Allo Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 904.8, "gross_charge": 1392.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500018", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "38215", "type": "HCPCS" } ], "description": "Hc Cell Concentration Buffy Coat Allo Harvest Cells For Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 965.9, "gross_charge": 1486.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500019", "type": "CDM" }, { "code": "302", "type": "RC" }, { "code": "86367", "type": "HCPCS" } ], "description": "Hc Stem Cells Total Count Cd34 Product", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 213.2, "gross_charge": 328.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500020", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "86367", "type": "HCPCS" } ], "description": "Hc Stem Cells Total Count Cd34 Allo Donor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 237.25, "gross_charge": 365.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500021", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "81265", "type": "HCPCS" } ], "description": "Hc Donor Comparative Analysis Str Markers Patient&Comp Spec So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 546.0, "gross_charge": 840.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500022", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "81266", "type": "HCPCS" } ], "description": "Hc Donor Comparative Analysis Str Markers Ea Addl Specimen So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 741.0, "gross_charge": 1140.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500023", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "81267", "type": "HCPCS" } ], "description": "Hc Donor Chimerism W/Comp To Baseline W/O Cell Selection So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 682.5, "gross_charge": 1050.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500024", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "81268", "type": "HCPCS" } ], "description": "Hc Donor Chimerism W/Comp To Baseline W/Cell Selection Ea So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1300.65, "gross_charge": 2001.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500025", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "81378", "type": "HCPCS" } ], "description": "Hc Donor Hla I&Ii High Resolution Hla-A -B -C And -Drb1 So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 643.5, "gross_charge": 990.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500026", "type": "CDM" }, { "code": "815", "type": "RC" }, { "code": "81382", "type": "HCPCS" } ], "description": "Hc Donor Hla Class Ii Typing High Resolution One Locus Ea So", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 643.5, "gross_charge": 990.0, "setting": "both" } ] }, { "code_information": [ { "code": "81500027", "type": "CDM" }, { "code": 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"type": "HCPCS" } ], "description": "Hc Nerve Conduction Studies 3-4", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1154.4, "gross_charge": 1776.0, "setting": "both" } ] }, { "code_information": [ { "code": "92200025", "type": "CDM" }, { "code": "922", "type": "RC" }, { "code": "95909", "type": "HCPCS" } ], "description": "Hc Nerve Conduction Studies 5-6", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1154.4, "gross_charge": 1776.0, "setting": "both" } ] }, { "code_information": [ { "code": "92200026", "type": "CDM" }, { "code": "922", "type": "RC" }, { "code": "95910", "type": "HCPCS" } ], "description": "Hc Nerve Conduction Studies 7-8", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1154.4, "gross_charge": 1776.0, "setting": "both" } ] }, { "code_information": [ { "code": "92200027", "type": "CDM" }, { "code": "922", "type": "RC" }, { "code": "95911", "type": "HCPCS" } ], "description": "Hc Nerve Conduction Studies 9-10", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1971.45, "gross_charge": 3033.0, "setting": "both" } ] }, { "code_information": [ { "code": "92200028", "type": "CDM" }, { "code": "922", "type": "RC" }, { "code": "95912", "type": "HCPCS" } ], "description": "Hc Nerve Conduction Studies 11-12", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1971.45, "gross_charge": 3033.0, "setting": "both" } ] }, { "code_information": [ { "code": "92200029", "type": "CDM" }, { "code": "922", "type": "RC" }, { "code": "95913", "type": "HCPCS" } ], "description": "Hc Nerve Conduction Studies 13 Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1971.45, "gross_charge": 3033.0, "setting": "both" } ] }, { "code_information": [ { "code": "92400001", "type": "CDM" }, { "code": "924", "type": "RC" }, { "code": "95070", "type": "HCPCS" } ], "description": "Hc Inhalation Bronch Challenge Test W/Histamine Methacholine Compound", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 1971.45, "gross_charge": 3033.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000001", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Nch Neonate Services 1-15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 53.3, "gross_charge": 82.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000002", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Nch Neonate Services 16-30 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 126.1, "gross_charge": 194.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000003", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Nch Neonate Services 31-45 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 200.85, "gross_charge": 309.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000004", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Nch Neonate Services 46 Min Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 282.75, "gross_charge": 435.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000005", "type": "CDM" }, { "code": "410", "type": "RC" }, { "code": "G0238", "type": "HCPCS" } ], "description": "Hc Other Resp Proc One On One Per 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 79.3, "gross_charge": 122.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000006", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Mind/Body Therapy Integrative Care", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000007", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Acupuncture Integrative Care", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000008", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Massage Integrative Care", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000009", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Nutrition Consult Integrative Care", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000010", "type": "CDM" }, { "code": "920", "type": "RC" }, { "code": "G0248", "type": "HCPCS" } ], "description": "Hc Demonstrate Use Home Inr Monitor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 138.45, "gross_charge": 213.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000011", "type": "CDM" }, { "code": "940", "type": "RC" } ], "description": "Hc Art Therapy Integrative Care", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000016", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "38240", "type": "HCPCS" } ], "description": "Hc Stem Cell Allogeneic Transplant Per Donor", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5963.75, "gross_charge": 9175.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000017", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "38241", "type": "HCPCS" } ], "description": "Hc Stem Cell Autologous Transplant", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 5281.25, "gross_charge": 8125.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000018", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "38242", "type": "HCPCS" } ], "description": "Hc Post-Allo Trnsplnt Donor Lymphocyte Inf After Relapse", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 3404.7, "gross_charge": 5238.0, "setting": "both" } ] }, { "code_information": [ { "code": "94000019", "type": "CDM" }, { "code": "940", "type": "RC" }, { "code": "38243", "type": "HCPCS" } ], "description": "Hc Post-Allo Trnsplnt Donor Lymphocyte Infusion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 4717.7, "gross_charge": 7258.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200001", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "97802", "type": "HCPCS" } ], "description": "Hc Medical Nutrition Assess Indiv Initial Ea 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.25, "gross_charge": 65.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200002", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "97803", "type": "HCPCS" } ], "description": "Hc Medical Nutrition Reassess Indiv Initial Ea 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.25, "gross_charge": 45.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200003", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "97804", "type": "HCPCS" } ], "description": "Hc Medical Nutrition Therapy Group Ea 30 Minutes", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 42.25, "gross_charge": 65.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200004", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Adapting Vlc Per Class", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200005", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Med Weight Re-Enroll Screen", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200006", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Med Weight Tx Screening Lc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 224.9, "gross_charge": 346.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200007", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Med Weight Tx Screening Tlc", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 224.9, "gross_charge": 346.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200008", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Med Wt Screen Promotion", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 114.4, "gross_charge": 176.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200009", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Med Wt Screen W/Outside Ekg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 169.65, "gross_charge": 261.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200010", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Med Wt Screen W/Outside Lab", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 186.55, "gross_charge": 287.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200011", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Med Wt Screen W/Outside Lab&Ekg", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.05, "gross_charge": 317.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200012", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Reduce Vlc Per Class", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200013", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Reduce Or Dm Type Ii Vlc Per Class", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200014", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Reducing Or Dm Lc Per Class", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200015", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Weight Maintnce Lc Per Class", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200016", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9449", "type": "HCPCS" } ], "description": "Hc Weight Maintnce Vlc Per Class", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 19.5, "gross_charge": 30.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200017", "type": "CDM" }, { "code": "510", "type": "RC" }, { "code": "99406", "type": "HCPCS" } ], "description": "Hc Smoke Tobacco Counseling 3-10 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200018", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "99407", "type": "HCPCS" } ], "description": "Hc Smoke Tobacco Counsel More Than 10 Mins", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 29.9, "gross_charge": 46.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200019", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "G0108", "type": "HCPCS" } ], "description": "Hc Train Therapy Diab Ind Session 30 M", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 60.45, "gross_charge": 93.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200020", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "G0109", "type": "HCPCS" } ], "description": "Hc Train Therapy Diab Grp Session 30 M", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 49.4, "gross_charge": 76.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200021", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "G0177", "type": "HCPCS" } ], "description": "Hc Train Educ Related To Care And Tx 45 Min Or More", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 265.85, "gross_charge": 409.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200022", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "G0270", "type": "HCPCS" } ], "description": "Hc Mnt Second Referral Per 15 Min", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 26.0, "gross_charge": 40.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200030", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9451", "type": "HCPCS" } ], "description": "Hc Fitness Consultation", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 60.45, "gross_charge": 93.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200031", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9452", "type": "HCPCS" } ], "description": "Hc Nutrition Therapy Group Educ Ob", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 118.3, "gross_charge": 182.0, "setting": "both" } ] }, { "code_information": [ { "code": "94200032", "type": "CDM" }, { "code": "942", "type": "RC" }, { "code": "S9470", "type": "HCPCS" } ], "description": "Hc Mcaid Ob Nutrition Intervention Diettcian", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 43.55, "gross_charge": 67.0, "setting": "both" } ] }, { "code_information": [ { "code": "94300001", "type": "CDM" }, { "code": "943", "type": "RC" }, { "code": "93797", "type": "HCPCS" } ], "description": "Hc Card Rehab Wo Mon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 206.7, "gross_charge": 318.0, "setting": "both" } ] }, { "code_information": [ { "code": "94300002", "type": "CDM" }, { "code": "943", "type": "RC" }, { "code": "93798", "type": "HCPCS" } ], "description": "Hc Card Rehab W Mon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 295.75, "gross_charge": 455.0, "setting": "both" } ] }, { "code_information": [ { "code": "94800002", "type": "CDM" }, { "code": "948", "type": "RC" }, { "code": "94625", "type": "HCPCS" } ], "description": "Hc Pulm Rehab Wo Oximetry Mon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.7, "gross_charge": 178.0, "setting": "both" } ] }, { "code_information": [ { "code": "94800003", "type": "CDM" }, { "code": "948", "type": "RC" }, { "code": "94626", "type": "HCPCS" } ], "description": "Hc Pulm Rehab W Cont Oximetry Mon", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard", "billing_class": "facility", "discounted_cash": 115.7, "gross_charge": 178.0, "setting": "both" } ] }, { "code_information": [ { "code": "99800001", "type": "CDM" }, { "code": "998", "type": "RC" } ], "description": "Hc Nonchargeable Equipment", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1889.22, "gross_charge": 2906.49, "setting": "both" } ] }, { "code_information": [ { "code": "99800171", "type": "CDM" }, { "code": "998", "type": "RC" } ], "description": "Hc Nonchargeable Supply", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 563.52, "gross_charge": 866.95, "setting": "both" } ] }, { "code_information": [ { "code": "99911111", "type": "CDM" }, { "code": "301", "type": "RC" } ], "description": "Hc Miscellaneous Charge", "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Standard | Price is variable based on underlying billing methodology - especially, for drug and supply items.", "billing_class": "facility", "discounted_cash": 1950.0, "gross_charge": 3000.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10000", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9181", "type": "HCPCS" }, { "code": "00143-9512-01", "type": "NDC" } ], "description": "ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 171.14, "gross_charge": 263.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10009", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1308", "type": "HCPCS" }, { "code": "63323-0738-09", "type": "NDC" } ], "description": "FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.62, "gross_charge": 34.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10010", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "27241-0249-49", "type": "NDC" } ], "description": "FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 24.41, "gross_charge": 37.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10011", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0595-01", "type": "NDC" } ], "description": "FAMOTIDINE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10012", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0398-03", "type": "NDC" } ], "description": "FAMOTIDINE 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10014", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0103-77", "type": "NDC" } ], "description": "FAT EMULSION 20 % INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 71.56, "gross_charge": 110.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10014", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0103-78", "type": "NDC" } ], "description": "FAT EMULSION 20 % INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 57.26, "gross_charge": 88.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10024", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "72578-0056-01", "type": "NDC" } ], "description": "FELBAMATE 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.84, "gross_charge": 7.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10025", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51525-0431-01", "type": "NDC" } ], "description": "FELBAMATE 600 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.15, "gross_charge": 17.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100272", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0597", "type": "HCPCS" }, { "code": "63833-0825-02", "type": "NDC" } ], "description": "C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11865.78, "gross_charge": 18255.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100344", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9319", "type": "HCPCS" }, { "code": "63323-0926-88", "type": "NDC" } ], "description": "ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7946.93, "gross_charge": 12226.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10036", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1442", "type": "HCPCS" }, { "code": "55513-0530-01", "type": "NDC" } ], "description": "FILGRASTIM 300 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 1018.29, "gross_charge": 1566.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10037", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0428-01", "type": "NDC" } ], "description": "FINASTERIDE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10041", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0321-15", "type": "NDC" } ], "description": "FLECAINIDE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.19, "gross_charge": 6.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10043", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-0010-20", "type": "NDC" } ], "description": "FLECAINIDE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10044", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0728-11", "type": "NDC" } ], "description": "FLUCONAZOLE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.23, "gross_charge": 8.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10045", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0735-01", "type": "NDC" } ], "description": "FLUCONAZOLE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.3, "gross_charge": 9.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10046", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0251-04", "type": "NDC" } ], "description": "FLUCONAZOLE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10049", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1450", "type": "HCPCS" }, { "code": "25021-0184-66", "type": "NDC" } ], "description": "FLUCONAZOLE 200 MG/100 ML IN SOD. CHLORIDE (ISO) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 43.26, "gross_charge": 66.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100491", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0165", "type": "HCPCS" }, { "code": "49502-0500-02", "type": "NDC" } ], "description": "EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 929.47, "gross_charge": 1429.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10050", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1450", "type": "HCPCS" }, { "code": "25021-0184-67", "type": "NDC" } ], "description": "FLUCONAZOLE 400 MG/200 ML IN SOD. CHLORIDE(ISO) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10051", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0599-21", "type": "NDC" } ], "description": "FLUCYTOSINE 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 114.17, "gross_charge": 175.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10052", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0610-21", "type": "NDC" } ], "description": "FLUCYTOSINE 500 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 197.7, "gross_charge": 304.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10054", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0330-15", "type": "NDC" } ], "description": "FLUDROCORTISONE 0.1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10059", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "A9612", "type": "HCPCS" }, { "code": "14789-0122-05", "type": "NDC" } ], "description": "FLUORESCEIN 500 MG/5 ML (10 %) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 124.64, "gross_charge": 191.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100611", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0953-01", "type": "NDC" } ], "description": "DICLOFENAC 1 % TOPICAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 GR", "billing_class": "facility", "discounted_cash": 34.74, "gross_charge": 53.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100614", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "82347-0405-05", "type": "NDC" } ], "description": "DICLOFENAC EPOLAMINE 1.3 % TRANSDERMAL 12 HOUR PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.28, "gross_charge": 23.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10065", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-4118-06", "type": "NDC" } ], "description": "FLUOROURACIL 5 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 40 GR", "billing_class": "facility", "discounted_cash": 73.58, "gross_charge": 113.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10069", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0399-00", "type": "NDC" } ], "description": "FLUOXETINE 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.06, "gross_charge": 4.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10070", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7346-61", "type": "NDC" } ], "description": "FLUOXETINE 20 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100740", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1742", "type": "HCPCS" }, { "code": "00009-3794-22", "type": "NDC" } ], "description": "IBUTILIDE FUMARATE 0.1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 290.91, "gross_charge": 447.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100796", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00591-2533-60", "type": "NDC" } ], "description": "DALFAMPRIDINE ER 10 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.39, "gross_charge": 6.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10085", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0159-01", "type": "NDC" } ], "description": "FLUVOXAMINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10093", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1455", "type": "HCPCS" }, { "code": "76310-0024-15", "type": "NDC" } ], "description": "FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 1045.98, "gross_charge": 1609.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-100995", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0420-95", "type": "NDC" } ], "description": "RITONAVIR 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.1, "gross_charge": 26.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-101", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6773-61", "type": "NDC" } ], "description": "ACETAMINOPHEN 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10101", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1570", "type": "HCPCS" }, { "code": "42023-0173-25", "type": "NDC" } ], "description": "GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 178.65, "gross_charge": 274.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10106", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1580", "type": "HCPCS" }, { "code": "00338-0503-48", "type": "NDC" } ], "description": "GENTAMICIN 80 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 43.91, "gross_charge": 67.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10108", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1580", "type": "HCPCS" }, { "code": "00338-0505-48", "type": "NDC" } ], "description": "GENTAMICIN 100 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 44.46, "gross_charge": 68.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10117", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0361-15", "type": "NDC" } ], "description": "GLIPIZIDE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10137", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9202", "type": "HCPCS" }, { "code": "70720-0950-36", "type": "NDC" } ], "description": "GOSERELIN 3.6 MG SUBCUTANEOUS IMPLANT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3099.3, "gross_charge": 4768.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10149", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68094-0065-62", "type": "NDC" } ], "description": "GUANFACINE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.12, "gross_charge": 12.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10159", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00713-0640-86", "type": "NDC" } ], "description": "HALOBETASOL PROPIONATE 0.05 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 GR", "billing_class": "facility", "discounted_cash": 48.23, "gross_charge": 74.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10162", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1631", "type": "HCPCS" }, { "code": "71288-0503-01", "type": "NDC" } ], "description": "HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 27.04, "gross_charge": 41.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10163", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1631", "type": "HCPCS" }, { "code": "71288-0502-01", "type": "NDC" } ], "description": "HALOPERIDOL DECANOATE 50 MG/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 32.08, "gross_charge": 49.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10176", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "63323-0540-13", "type": "NDC" } ], "description": "HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.05, "gross_charge": 37.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10181", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "63323-0262-26", "type": "NDC" } ], "description": "HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.24, "gross_charge": 37.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10210", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0138-07", "type": "NDC" } ], "description": "HYDROCORTISONE 100 MG/60 ML ENEMA", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 43.29, "gross_charge": 66.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10225", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "42858-0304-16", "type": "NDC" } ], "description": "HYDROMORPHONE 1 MG/ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 6.11, "gross_charge": 9.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10227", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-7224-06", "type": "NDC" } ], "description": "HYDROMORPHONE 3 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 29.93, "gross_charge": 46.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10235", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0269-01", "type": "NDC" } ], "description": "HYDROXYCHLOROQUINE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10236", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0284-01", "type": "NDC" } ], "description": "HYDROXYUREA 500 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.29, "gross_charge": 6.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10239", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1980", "type": "HCPCS" }, { "code": "54288-0111-01", "type": "NDC" } ], "description": "HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 89.21, "gross_charge": 137.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10246", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1828-00", "type": "NDC" } ], "description": "IBUPROFEN 100 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.49, "gross_charge": 0.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10248", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9208", "type": "HCPCS" }, { "code": "63323-0142-10", "type": "NDC" } ], "description": "IFOSFAMIDE 1 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 198.7, "gross_charge": 305.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10266", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "70100-0424-01", "type": "NDC" } ], "description": "INDOCYANINE GREEN 25 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 516.85, "gross_charge": 795.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10286", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" }, { "code": "00002-8715-01", "type": "NDC" } ], "description": "INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 82.36, "gross_charge": 126.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10289", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" }, { "code": "00002-0213-01", "type": "NDC" } ], "description": "INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 35.98, "gross_charge": 55.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10323", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-1414-91", "type": "NDC" } ], "description": "IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 112.61, "gross_charge": 173.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10323", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9967", "type": "HCPCS" }, { "code": "00407-1414-72", "type": "NDC" } ], "description": "IOHEXOL 350 MG IODINE/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 114.17, "gross_charge": 175.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10328", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9967", "type": "HCPCS" }, { "code": "00270-1316-52", "type": "NDC" } ], "description": "IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10358", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9968", "type": "HCPCS" }, { "code": "67457-0220-05", "type": "NDC" } ], "description": "ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 337.97, "gross_charge": 519.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10364", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0299-25", "type": "NDC" } ], "description": "ITRACONAZOLE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.26, "gross_charge": 12.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10368", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00168-0099-15", "type": "NDC" } ], "description": "KETOCONAZOLE 2 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 41.34, "gross_charge": 63.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10369", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64380-0827-06", "type": "NDC" } ], "description": "KETOCONAZOLE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.97, "gross_charge": 7.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10373", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0439-11", "type": "NDC" } ], "description": "LABETALOL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10375", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0383-03", "type": "NDC" } ], "description": "LABETALOL 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10380", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0525-55", "type": "NDC" } ], "description": "AMMONIUM LACTATE 12 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 225 GR", "billing_class": "facility", "discounted_cash": 32.56, "gross_charge": 50.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-103890", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0299-01", "type": "NDC" } ], "description": "TAMSULOSIN 0.4 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10394", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0505-05", "type": "NDC" } ], "description": "LEVOBUNOLOL 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 47.0, "gross_charge": 72.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-104", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-2116-02", "type": "NDC" } ], "description": "ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.55, "gross_charge": 0.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10403", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42292-0038-20", "type": "NDC" } ], "description": "LEVOTHYROXINE 88 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.93, "gross_charge": 6.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10404", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0508-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 112 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10406", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0541-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 175 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.1, "gross_charge": 6.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-104207", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "55150-0163-30", "type": "NDC" } ], "description": "LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 25.42, "gross_charge": 39.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-104208", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "63323-0496-97", "type": "NDC" } ], "description": "LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 42.44, "gross_charge": 65.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10427", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2004", "type": "HCPCS" }, { "code": "63323-0482-03", "type": "NDC" } ], "description": "LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.1, "gross_charge": 34.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10430", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2004", "type": "HCPCS" }, { "code": "63323-0483-03", "type": "NDC" } ], "description": "LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.1, "gross_charge": 34.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10431", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2004", "type": "HCPCS" }, { "code": "63323-0489-27", "type": "NDC" } ], "description": "LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.34, "gross_charge": 37.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10434", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62332-0582-31", "type": "NDC" } ], "description": "LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 55.93, "gross_charge": 86.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10443", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42794-0018-12", "type": "NDC" } ], "description": "LIOTHYRONINE 5 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.96, "gross_charge": 6.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10449", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6798-61", "type": "NDC" } ], "description": "LISINOPRIL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1045", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-0510-00", "type": "NDC" } ], "description": "BETHANECHOL CHLORIDE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10451", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6797-61", "type": "NDC" } ], "description": "LISINOPRIL 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10454", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0640-01", "type": "NDC" } ], "description": "LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10455", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0655-01", "type": "NDC" } ], "description": "LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-104555", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7527", "type": "HCPCS" }, { "code": "67877-0718-33", "type": "NDC" } ], "description": "EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.65, "gross_charge": 14.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-104576", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0750-21", "type": "NDC" } ], "description": "TRANEXAMIC ACID 650 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.52, "gross_charge": 13.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-104604", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65649-0303-03", "type": "NDC" } ], "description": "RIFAXIMIN 550 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 117.0, "gross_charge": 180.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10466", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0248-01", "type": "NDC" } ], "description": "LORATADINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10467", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2060", "type": "HCPCS" }, { "code": "00641-6044-25", "type": "NDC" } ], "description": "LORAZEPAM 2 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 22.3, "gross_charge": 34.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10467", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2060", "type": "HCPCS" }, { "code": "00641-6050-01", "type": "NDC" } ], "description": "LORAZEPAM 2 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 22.23, "gross_charge": 34.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10468", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2060", "type": "HCPCS" }, { "code": "00641-6051-01", "type": "NDC" } ], "description": "LORAZEPAM 4 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 50.47, "gross_charge": 77.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10475", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7504", "type": "HCPCS" }, { "code": "00009-7224-02", "type": "NDC" } ], "description": "LYMPHOCYTE,ANTI-THYMO IMMUNE GLOBULIN 50 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 16063.22, "gross_charge": 24712.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0730-30", "type": "NDC" } ], "description": "ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.23, "gross_charge": 0.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10512", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90707", "type": "HCPCS" }, { "code": "00006-4681-00", "type": "NDC" } ], "description": "MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 294.94, "gross_charge": 453.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10521", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49884-0907-05", "type": "NDC" } ], "description": "MEGESTROL 400 MG/10 ML (40 MG/ML) ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10522", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9245", "type": "HCPCS" }, { "code": "71288-0132-90", "type": "NDC" } ], "description": "MELPHALAN HCL 50 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 554.52, "gross_charge": 853.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10531", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69076-0913-02", "type": "NDC" } ], "description": "MERCAPTOPURINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.73, "gross_charge": 10.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10535", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0098-51", "type": "NDC" } ], "description": "MESALAMINE 4 GRAM/60 ML ENEMA", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 18.82, "gross_charge": 28.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10537", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9209", "type": "HCPCS" }, { "code": "10019-0953-01", "type": "NDC" } ], "description": "MESNA 100 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 74.52, "gross_charge": 114.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10544", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0155-01", "type": "NDC" } ], "description": "METFORMIN 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10546", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1230", "type": "HCPCS" }, { "code": "51991-0002-98", "type": "NDC" } ], "description": "METHADONE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 587.86, "gross_charge": 904.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10549", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0694-21", "type": "NDC" } ], "description": "METHENAMINE HIPPURATE 1 GRAM TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.4, "gross_charge": 9.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105502", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0897", "type": "HCPCS" }, { "code": "55513-0710-21", "type": "NDC" } ], "description": "DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 5965.05, "gross_charge": 9177.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10553", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "23155-0070-01", "type": "NDC" } ], "description": "METHIMAZOLE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105552", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0703", "type": "HCPCS" }, { "code": "00264-3195-11", "type": "NDC" } ], "description": "CEFEPIME 2 GRAM/50 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 81.41, "gross_charge": 125.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105633", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0468-17", "type": "NDC" } ], "description": "BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 32.92, "gross_charge": 50.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105640", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0665", "type": "HCPCS" }, { "code": "55150-0169-10", "type": "NDC" } ], "description": "BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 23.76, "gross_charge": 36.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105644", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9043", "type": "HCPCS" }, { "code": "00024-5824-11", "type": "NDC" } ], "description": "CABAZITAXEL 10 MG/ML (FIRST DILUTION) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 35273.55, "gross_charge": 54267.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105698", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3535", "type": "HCPCS" }, { "code": "78206-0127-02", "type": "NDC" } ], "description": "MOMETASONE-FORMOTEROL HFA 100 MCG-5 MCG/ACTUATION AEROSOL INHALER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8.8 GR", "billing_class": "facility", "discounted_cash": 158.54, "gross_charge": 243.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105699", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3535", "type": "HCPCS" }, { "code": "78206-0126-02", "type": "NDC" } ], "description": "MOMETASONE-FORMOTEROL HFA 200 MCG-5 MCG/ACTUATION AEROSOL INHALER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8.8 GR", "billing_class": "facility", "discounted_cash": 158.54, "gross_charge": 243.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10571", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2210", "type": "HCPCS" }, { "code": "51991-0144-17", "type": "NDC" } ], "description": "METHYLERGONOVINE 0.2 MG/ML (1 ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 70.98, "gross_charge": 109.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10577", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0698-01", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 153.82, "gross_charge": 236.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10578", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "43598-0129-01", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SODIUM SUCCINATE 125 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 28.47, "gross_charge": 43.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10580", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "63323-0255-01", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 39.68, "gross_charge": 61.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10581", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0758-01", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 94.44, "gross_charge": 145.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10586", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-6174-01", "type": "NDC" } ], "description": "METOLAZONE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.6, "gross_charge": 11.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10587", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0624-11", "type": "NDC" } ], "description": "METOLAZONE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10588", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0024-01", "type": "NDC" } ], "description": "METOLAZONE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.06, "gross_charge": 12.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105899", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "63323-0559-65", "type": "NDC" } ], "description": "ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 28.83, "gross_charge": 44.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105900", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "63323-0564-97", "type": "NDC" } ], "description": "ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 30.36, "gross_charge": 46.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105901", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "25021-0410-77", "type": "NDC" } ], "description": "ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 31.69, "gross_charge": 48.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105902", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "63323-0584-21", "type": "NDC" } ], "description": "ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 41.73, "gross_charge": 64.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105903", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "63323-0586-96", "type": "NDC" } ], "description": "ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 46.9, "gross_charge": 72.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105904", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "71288-0437-92", "type": "NDC" } ], "description": "ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 40.98, "gross_charge": 63.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-105906", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24979-0004-07", "type": "NDC" } ], "description": "DONEPEZIL 23 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10592", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0139-70", "type": "NDC" } ], "description": "METRONIDAZOLE 0.75 % (37.5 MG/5 GRAM) VAGINAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 70 GR", "billing_class": "facility", "discounted_cash": 55.74, "gross_charge": 85.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10595", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0778-21", "type": "NDC" } ], "description": "MEXILETINE 150 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10596", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-8740-01", "type": "NDC" } ], "description": "MEXILETINE 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.95, "gross_charge": 9.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10597", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0241-01", "type": "NDC" } ], "description": "MEXILETINE 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.32, "gross_charge": 6.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10599", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "46122-0444-27", "type": "NDC" } ], "description": "MICONAZOLE NITRATE 2 % TOPICAL POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 71 GR", "billing_class": "facility", "discounted_cash": 1.72, "gross_charge": 2.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106061", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "10572-0012-01", "type": "NDC" } ], "description": "SODIUM,POTASSIUM,MAG SULFATES 17.5 GRAM-3.13 GRAM-1.6 GRAM ORAL SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 177 ML", "billing_class": "facility", "discounted_cash": 85.02, "gross_charge": 130.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106079", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "73302-0456-01", "type": "NDC" } ], "description": "ULIPRISTAL 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 75.79, "gross_charge": 116.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10609", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0387-01", "type": "NDC" } ], "description": "MIDODRINE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.16, "gross_charge": 6.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10610", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0398-01", "type": "NDC" } ], "description": "MIDODRINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.13, "gross_charge": 6.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10612", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2265", "type": "HCPCS" }, { "code": "70842-0160-01", "type": "NDC" } ], "description": "MINOCYCLINE 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 858.49, "gross_charge": 1320.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106120", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "A9589", "type": "HCPCS" }, { "code": "10511-3001-02", "type": "NDC" } ], "description": "HEXAMINOLEVULINATE 100 MG INTRAVESICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4303.13, "gross_charge": 6620.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106176", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0572", "type": "HCPCS" }, { "code": "43598-0579-30", "type": "NDC" } ], "description": "BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL FILM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.56, "gross_charge": 14.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106177", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0574", "type": "HCPCS" }, { "code": "43598-0582-30", "type": "NDC" } ], "description": "BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL FILM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14.27, "gross_charge": 21.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106249", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0631-36", "type": "NDC" } ], "description": "NEOMYCIN 3.5 MG/G-POLYMYXIN B 10,000 UNIT/G-DEXAMETH 0.1 % EYE OINT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 GR", "billing_class": "facility", "discounted_cash": 45.11, "gross_charge": 69.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106274", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0257", "type": "HCPCS" }, { "code": "00944-2884-02", "type": "NDC" } ], "description": "ALPHA-1-PROTEINASE INHIBITOR (HUMAN) 20 MG/ML (2 %) INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2603.74, "gross_charge": 4005.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106278", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3360", "type": "HCPCS" }, { "code": "69339-0136-97", "type": "NDC" } ], "description": "DIAZEPAM 5 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 33.86, "gross_charge": 52.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10628", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0735-11", "type": "NDC" } ], "description": "MISOPROSTOL 100 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10629", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0746-01", "type": "NDC" } ], "description": "MISOPROSTOL 200 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.11, "gross_charge": 9.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10630", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9280", "type": "HCPCS" }, { "code": "00143-9135-01", "type": "NDC" } ], "description": "MITOMYCIN 20 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.02 GR", "billing_class": "facility", "discounted_cash": 191.2, "gross_charge": 294.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106348", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2405", "type": "HCPCS" }, { "code": "00641-6078-25", "type": "NDC" } ], "description": "ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 22.62, "gross_charge": 34.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106363", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-4278-16", "type": "NDC" } ], "description": "LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 28.28, "gross_charge": 43.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106364", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0462-17", "type": "NDC" } ], "description": "BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 33.18, "gross_charge": 51.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106443", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9171", "type": "HCPCS" }, { "code": "16729-0267-63", "type": "NDC" } ], "description": "DOCETAXEL 20 MG/ML (1 ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 121.62, "gross_charge": 187.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106490", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00597-0355-56", "type": "NDC" } ], "description": "DABIGATRAN ETEXILATE 75 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.9, "gross_charge": 13.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10655", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-8003-30", "type": "NDC" } ], "description": "MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10674", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0180-22", "type": "NDC" } ], "description": "MUPIROCIN 2 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 22 GR", "billing_class": "facility", "discounted_cash": 14.3, "gross_charge": 22.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106783", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1453", "type": "HCPCS" }, { "code": "00143-9428-01", "type": "NDC" } ], "description": "FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 92.14, "gross_charge": 141.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-106804", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0897", "type": "HCPCS" }, { "code": "55513-0730-01", "type": "NDC" } ], "description": "DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.7 ML", "billing_class": "facility", "discounted_cash": 10954.38, "gross_charge": 16852.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10685", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0291-21", "type": "NDC" } ], "description": "NALTREXONE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.9, "gross_charge": 12.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1069", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "40985-0277-57", "type": "NDC" } ], "description": "BIOTIN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10708", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0830-60", "type": "NDC" } ], "description": "NEOMYCIN-POLYMYXIN-DEXAMETH 3.5 MG/ML-10,000 UNIT/ML-0.1% EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 45.44, "gross_charge": 69.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10717", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1362-23", "type": "NDC" } ], "description": "NICOTINE (POLACRILEX) 2 MG GUM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10722", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "23155-0512-00", "type": "NDC" } ], "description": "NIMODIPINE 30 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.26, "gross_charge": 8.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10723", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0593-24", "type": "NDC" } ], "description": "NITROFURANTOIN 25 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 230 ML", "billing_class": "facility", "discounted_cash": 1747.4, "gross_charge": 2688.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10734", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "72078-0002-04", "type": "NDC" } ], "description": "NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 34.81, "gross_charge": 53.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10735", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00555-9026-58", "type": "NDC" } ], "description": "NORETHINDRONE 1 MG-ETHINYL ESTRADIOL 20 MCG (21)-IRON 75 MG (7) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 28 UN", "billing_class": "facility", "discounted_cash": 10.79, "gross_charge": 16.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10747", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0304-50", "type": "NDC" } ], "description": "NORETHINDRONE ACETATE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.13, "gross_charge": 6.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10749", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70700-0119-85", "type": "NDC" } ], "description": "NORGESTIMATE 0.25 MG-ETHINYL ESTRADIOL 0.035 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 28 UN", "billing_class": "facility", "discounted_cash": 15.8, "gross_charge": 24.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107660", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-3656-21", "type": "NDC" } ], "description": "BUPRENORPHINE 5 MCG/HOUR WEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 102.44, "gross_charge": 157.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107661", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42858-0493-40", "type": "NDC" } ], "description": "BUPRENORPHINE 10 MCG/HOUR WEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 103.22, "gross_charge": 158.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107668", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0758-11", "type": "NDC" } ], "description": "LURASIDONE 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.03, "gross_charge": 12.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107669", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0780-21", "type": "NDC" } ], "description": "LURASIDONE 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.16, "gross_charge": 12.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107671", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0712", "type": "HCPCS" }, { "code": "00456-0600-10", "type": "NDC" } ], "description": "CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 634.46, "gross_charge": 976.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107798", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0476", "type": "HCPCS" }, { "code": "25021-0681-71", "type": "NDC" } ], "description": "BACLOFEN 50 MCG/ML (1 ML) INTRATHECAL SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 37.5, "gross_charge": 57.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107799", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0475", "type": "HCPCS" }, { "code": "66794-0155-02", "type": "NDC" } ], "description": "BACLOFEN 10,000 MCG/20 ML (500 MCG/ML) INTRATHECAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 329.81, "gross_charge": 507.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-107800", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0475", "type": "HCPCS" }, { "code": "25021-0679-20", "type": "NDC" } ], "description": "BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 888.03, "gross_charge": 1366.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10781", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00065-0795-15", "type": "NDC" } ], "description": "BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 21.26, "gross_charge": 32.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10782", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "10119-0002-52", "type": "NDC" } ], "description": "SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 120 ML", "billing_class": "facility", "discounted_cash": 1.95, "gross_charge": 3.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1079", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6407-61", "type": "NDC" } ], "description": "BISACODYL 5 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1080", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00597-0052-38", "type": "NDC" } ], "description": "BISACODYL 10 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108021", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0134", "type": "HCPCS" }, { "code": "63323-0434-00", "type": "NDC" } ], "description": "ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 75 ML", "billing_class": "facility", "discounted_cash": 34.9, "gross_charge": 53.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108028", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1652", "type": "HCPCS" }, { "code": "55150-0232-10", "type": "NDC" } ], "description": "FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 47.12, "gross_charge": 72.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108029", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1652", "type": "HCPCS" }, { "code": "67457-0585-08", "type": "NDC" } ], "description": "FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 117.91, "gross_charge": 181.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108042", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0881", "type": "HCPCS" }, { "code": "55513-0021-04", "type": "NDC" } ], "description": "DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 1001.42, "gross_charge": 1540.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108043", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0881", "type": "HCPCS" }, { "code": "55513-0023-01", "type": "NDC" } ], "description": "DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 1491.42, "gross_charge": 2294.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108047", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0881", "type": "HCPCS" }, { "code": "55513-0028-01", "type": "NDC" } ], "description": "DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 4921.51, "gross_charge": 7571.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108049", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0561", "type": "HCPCS" }, { "code": "60793-0701-10", "type": "NDC" } ], "description": "PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 1133.7, "gross_charge": 1744.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108050", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0561", "type": "HCPCS" }, { "code": "60793-0702-04", "type": "NDC" } ], "description": "PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 2300.74, "gross_charge": 3539.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108061", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3262", "type": "HCPCS" }, { "code": "50242-0135-01", "type": "NDC" } ], "description": "TOCILIZUMAB 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 1452.94, "gross_charge": 2235.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108062", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3262", "type": "HCPCS" }, { "code": "50242-0136-01", "type": "NDC" } ], "description": "TOCILIZUMAB 200 MG/10 ML (20 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 3552.38, "gross_charge": 5465.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108063", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3262", "type": "HCPCS" }, { "code": "50242-0137-01", "type": "NDC" } ], "description": "TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 7051.43, "gross_charge": 10848.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108065", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9035", "type": "HCPCS" }, { "code": "50242-0061-01", "type": "NDC" } ], "description": "BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.05 ML", "billing_class": "facility", "discounted_cash": 313.98, "gross_charge": 483.05, "setting": "both" }, { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.05 ML | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient", "billing_class": "facility", "discounted_cash": 313.98, "gross_charge": 483.05, "modifiers": "JW", "setting": "both" } ] }, { "code_information": [ { "code": "RX-108072", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9055", "type": "HCPCS" }, { "code": "66733-0958-23", "type": "NDC" } ], "description": "CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 4461.6, "gross_charge": 6864.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108074", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1442", "type": "HCPCS" }, { "code": "55513-0546-01", "type": "NDC" } ], "description": "FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.6 ML", "billing_class": "facility", "discounted_cash": 1608.78, "gross_charge": 2475.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108096", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9395", "type": "HCPCS" }, { "code": "25021-0462-74", "type": "NDC" } ], "description": "FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 445.61, "gross_charge": 685.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10810", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "54838-0510-80", "type": "NDC" } ], "description": "OXYBUTYNIN CHLORIDE 5 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108108", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2426", "type": "HCPCS" }, { "code": "50458-0562-01", "type": "NDC" } ], "description": "PALIPERIDONE PALMITATE 117 MG/0.75 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.75 ML", "billing_class": "facility", "discounted_cash": 5564.49, "gross_charge": 8560.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108109", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2426", "type": "HCPCS" }, { "code": "50458-0564-01", "type": "NDC" } ], "description": "PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.5 ML", "billing_class": "facility", "discounted_cash": 11107.72, "gross_charge": 17088.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108118", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1956", "type": "HCPCS" }, { "code": "00143-9315-24", "type": "NDC" } ], "description": "LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 42.02, "gross_charge": 64.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108119", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1956", "type": "HCPCS" }, { "code": "00143-9316-24", "type": "NDC" } ], "description": "LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 43.39, "gross_charge": 66.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10812", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-8557-30", "type": "NDC" } ], "description": "OXYCODONE 20 MG/ML ORAL CONCENTRATE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 117.46, "gross_charge": 180.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108120", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1956", "type": "HCPCS" }, { "code": "00143-9317-24", "type": "NDC" } ], "description": "LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 150 ML", "billing_class": "facility", "discounted_cash": 43.91, "gross_charge": 67.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108121", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2543", "type": "HCPCS" }, { "code": "00338-9638-12", "type": "NDC" } ], "description": "PIPERACILLIN-TAZOBACTAM 4.5 GRAM/100 ML DEXTROSE(ISO-OSM) IV PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 107.38, "gross_charge": 165.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10813", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0406-67", "type": "NDC" } ], "description": "OXYCODONE 5 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 11.86, "gross_charge": 18.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108130", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0744", "type": "HCPCS" }, { "code": "25021-0192-82", "type": "NDC" } ], "description": "CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 43.91, "gross_charge": 67.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108132", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0744", "type": "HCPCS" }, { "code": "25021-0192-87", "type": "NDC" } ], "description": "CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 45.27, "gross_charge": 69.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108133", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0278", "type": "HCPCS" }, { "code": "23155-0290-42", "type": "NDC" } ], "description": "AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 35.07, "gross_charge": 53.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10814", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65162-0047-10", "type": "NDC" } ], "description": "OXYCODONE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.66, "gross_charge": 8.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108150", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90740", "type": "HCPCS" }, { "code": "00006-4992-00", "type": "NDC" } ], "description": "HEPATITIS B VIRUS VACCINE RECOMB (PF) 40 MCG/ML INTRAMUSCULAR SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 363.12, "gross_charge": 558.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108155", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0475", "type": "HCPCS" }, { "code": "70257-0560-01", "type": "NDC" } ], "description": "BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 496.4, "gross_charge": 763.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108155", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0475", "type": "HCPCS" }, { "code": "70257-0560-02", "type": "NDC" } ], "description": "BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 496.4, "gross_charge": 763.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108156", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0475", "type": "HCPCS" }, { "code": "70257-0561-02", "type": "NDC" } ], "description": "BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 1430.06, "gross_charge": 2200.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10839", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "52268-0100-01", "type": "NDC" } ], "description": "PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4000 ML", "billing_class": "facility", "discounted_cash": 60.06, "gross_charge": 92.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108421", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3816-03", "type": "NDC" } ], "description": "DASATINIB 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 203.32, "gross_charge": 312.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108422", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3817-03", "type": "NDC" } ], "description": "DASATINIB 140 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 232.54, "gross_charge": 357.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10855", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68382-0098-16", "type": "NDC" } ], "description": "PAROXETINE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10856", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0046-01", "type": "NDC" } ], "description": "PAROXETINE 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108590", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9351", "type": "HCPCS" }, { "code": "16729-0243-31", "type": "NDC" } ], "description": "TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 173.55, "gross_charge": 267.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1088", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "38779-1046-04", "type": "NDC" } ], "description": "BISMUTH SUBGALLATE (BULK) POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 GR", "billing_class": "facility", "discounted_cash": 39.91, "gross_charge": 61.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108842", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0490", "type": "HCPCS" }, { "code": "49401-0101-01", "type": "NDC" } ], "description": "BELIMUMAB 120 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1799.07, "gross_charge": 2767.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108843", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0490", "type": "HCPCS" }, { "code": "49401-0102-01", "type": "NDC" } ], "description": "BELIMUMAB 400 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5871.9, "gross_charge": 9033.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108850", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "77333-0951-10", "type": "NDC" } ], "description": "VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10894", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "25010-0705-15", "type": "NDC" } ], "description": "PENICILLAMINE 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 494.81, "gross_charge": 761.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108955", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9228", "type": "HCPCS" }, { "code": "00003-2327-11", "type": "NDC" } ], "description": "IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 24467.33, "gross_charge": 37642.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-108956", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9228", "type": "HCPCS" }, { "code": "00003-2328-22", "type": "NDC" } ], "description": "IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 40 ML", "billing_class": "facility", "discounted_cash": 97709.14, "gross_charge": 150321.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1090", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "01490-0039-04", "type": "NDC" } ], "description": "BISMUTH SUBSALICYLATE 262 MG/15 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 120 ML", "billing_class": "facility", "discounted_cash": 1.33, "gross_charge": 2.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10900", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" }, { "code": "00338-1025-41", "type": "NDC" } ], "description": "PENICILLIN G POT 3 MILLION UNIT/50 ML-DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 47.06, "gross_charge": 72.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-109034", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0706", "type": "HCPCS" }, { "code": "25021-0601-03", "type": "NDC" } ], "description": "CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 34.97, "gross_charge": 53.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10910", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9268", "type": "HCPCS" }, { "code": "00409-0801-01", "type": "NDC" } ], "description": "PENTOSTATIN 10 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6424.66, "gross_charge": 9884.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-109401", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0786-11", "type": "NDC" } ], "description": "ROFLUMILAST 500 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.92, "gross_charge": 10.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-109402", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00456-1110-30", "type": "NDC" } ], "description": "VILAZODONE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.84, "gross_charge": 39.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-109403", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-4373-03", "type": "NDC" } ], "description": "VILAZODONE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.61, "gross_charge": 19.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-10947", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2760", "type": "HCPCS" }, { "code": "68094-0101-20", "type": "NDC" } ], "description": "PHENTOLAMINE 5 MG INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 982.96, "gross_charge": 1512.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-109817", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0883", "type": "HCPCS" }, { "code": "25021-0414-50", "type": "NDC" } ], "description": "ARGATROBAN 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 170.17, "gross_charge": 261.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-109909", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "59676-0278-01", "type": "NDC" } ], "description": "RILPIVIRINE HCL 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 95.88, "gross_charge": 147.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11018", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0156-25", "type": "NDC" } ], "description": "PHENYTOIN 50 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.91, "gross_charge": 7.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11019", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00071-3740-66", "type": "NDC" } ], "description": "PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11023", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3430", "type": "HCPCS" }, { "code": "00409-9158-11", "type": "NDC" } ], "description": "PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 33.93, "gross_charge": 52.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11024", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0381-94", "type": "NDC" } ], "description": "PHYTONADIONE (VITAMIN K1) 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 102.44, "gross_charge": 157.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110250", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50458-0580-10", "type": "NDC" } ], "description": "RIVAROXABAN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.07, "gross_charge": 47.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110258", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0283", "type": "HCPCS" }, { "code": "43066-0360-20", "type": "NDC" } ], "description": "AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 79.59, "gross_charge": 122.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110306", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1740", "type": "HCPCS" }, { "code": "25021-0822-73", "type": "NDC" } ], "description": "IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 808.8, "gross_charge": 1244.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110360", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "52015-0080-01", "type": "NDC" } ], "description": "FIDAXOMICIN 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 242.48, "gross_charge": 373.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110361", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-0277-46", "type": "NDC" } ], "description": "VITAMIN E (DL, ACETATE) 450 MG (1,000 UNIT) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110427", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00186-0777-39", "type": "NDC" } ], "description": "TICAGRELOR 90 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.48, "gross_charge": 26.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11046", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "77333-0120-25", "type": "NDC" } ], "description": "CALCIUM POLYCARBOPHIL 625 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.36, "gross_charge": 0.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11050", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-5395-61", "type": "NDC" } ], "description": "POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11067", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0764-25", "type": "NDC" } ], "description": "SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.81, "gross_charge": 7.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11074", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0709-48", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 45.27, "gross_charge": 69.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110751", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" }, { "code": "00074-3473-03", "type": "NDC" } ], "description": "LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2852.85, "gross_charge": 4389.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11076", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "14789-0108-10", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 125.9, "gross_charge": 193.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11079", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0703-48", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 45.01, "gross_charge": 69.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11081", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0691-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.38, "gross_charge": 71.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11082", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0695-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11083", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0850-32", "type": "NDC" } ], "description": "POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.96, "gross_charge": 10.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-110998", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00004-0822-05", "type": "NDC" } ], "description": "OSELTAMIVIR 6 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.33333333333333 ML", "billing_class": "facility", "discounted_cash": 19.89, "gross_charge": 30.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11111", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0897-11", "type": "NDC" } ], "description": "PRAVASTATIN 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.8, "gross_charge": 5.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11112", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0908-11", "type": "NDC" } ], "description": "PRAVASTATIN 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.13, "gross_charge": 6.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-111196", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "20555-0019-00", "type": "NDC" } ], "description": "FERROUS GLUCONATE 324 MG (37.5 MG IRON) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-111216", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "10481-0111-08", "type": "NDC" } ], "description": "IODINE-POTASSIUM IODIDE 5 %-10 % TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8 ML", "billing_class": "facility", "discounted_cash": 36.95, "gross_charge": 56.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-111273", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "61958-1101-01", "type": "NDC" } ], "description": "EMTRICITABINE 200 MG-RILPIVIRINE 25 MG-TENOFOVIR DISPROX 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 255.55, "gross_charge": 393.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11129", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0202-01", "type": "NDC" } ], "description": "PRIMIDONE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.22, "gross_charge": 6.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-111348", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9042", "type": "HCPCS" }, { "code": "51144-0050-01", "type": "NDC" } ], "description": "BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34230.69, "gross_charge": 52662.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11138", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-7226-12", "type": "NDC" } ], "description": "PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.92, "gross_charge": 29.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-111395", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1744", "type": "HCPCS" }, { "code": "63323-0574-86", "type": "NDC" } ], "description": "ICATIBANT 30 MG/3 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 3939.88, "gross_charge": 6061.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11143", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00713-0536-12", "type": "NDC" } ], "description": "PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.45, "gross_charge": 13.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-111437", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3424", "type": "HCPCS" }, { "code": "50633-0310-11", "type": "NDC" } ], "description": "HYDROXOCOBALAMIN 5 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3180.35, "gross_charge": 4892.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11144", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00713-0526-12", "type": "NDC" } ], "description": "PROMETHAZINE 25 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 13.84, "gross_charge": 21.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11146", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0230-01", "type": "NDC" } ], "description": "PROPAFENONE 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11150", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2704", "type": "HCPCS" }, { "code": "63323-0269-37", "type": "NDC" } ], "description": "PROPOFOL 10 MG/ML INTRAVENOUS EMULSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 22.0, "gross_charge": 33.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70756-0720-11", "type": "NDC" } ], "description": "ACETAZOLAMIDE 125 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11218", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "37000-0024-04", "type": "NDC" } ], "description": "PSYLLIUM HUSK 3.4 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.29, "gross_charge": 0.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11237", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00781-3040-72", "type": "NDC" } ], "description": "PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11238", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42192-0626-16", "type": "NDC" } ], "description": "PYRIDOSTIGMINE BROMIDE 60 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.66666666666666 ML", "billing_class": "facility", "discounted_cash": 6.6, "gross_charge": 10.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11239", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0494-01", "type": "NDC" } ], "description": "PYRIDOSTIGMINE BROMIDE 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.68, "gross_charge": 7.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11240", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0220-03", "type": "NDC" } ], "description": "PYRIDOSTIGMINE BROMIDE ER 180 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.02, "gross_charge": 16.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112481", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "67850-0141-00", "type": "NDC" } ], "description": "POLIDOCANOL 1 % (20 MG/2 ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 89.54, "gross_charge": 137.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11259", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0431-03", "type": "NDC" } ], "description": "RAMIPRIL 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11261", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0430-00", "type": "NDC" } ], "description": "RAMIPRIL 5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112703", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0423-21", "type": "NDC" } ], "description": "CLOBAZAM 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.28, "gross_charge": 11.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112781", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0666", "type": "HCPCS" }, { "code": "65250-0266-09", "type": "NDC" } ], "description": "BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 1040.36, "gross_charge": 1600.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112787", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9201", "type": "HCPCS" }, { "code": "00409-0181-25", "type": "NDC" } ], "description": "GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 26.3 ML", "billing_class": "facility", "discounted_cash": 81.93, "gross_charge": 126.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112788", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9201", "type": "HCPCS" }, { "code": "00409-0182-25", "type": "NDC" } ], "description": "GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 52.6 ML", "billing_class": "facility", "discounted_cash": 124.41, "gross_charge": 191.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112834", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50458-0578-30", "type": "NDC" } ], "description": "RIVAROXABAN 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.07, "gross_charge": 47.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112835", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50458-0579-10", "type": "NDC" } ], "description": "RIVAROXABAN 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.07, "gross_charge": 47.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11287", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0207-68", "type": "NDC" } ], "description": "RIBAVIRIN 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.16, "gross_charge": 6.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11290", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70954-0041-10", "type": "NDC" } ], "description": "RIFABUTIN 150 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.1, "gross_charge": 27.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11291", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2804", "type": "HCPCS" }, { "code": "67457-0445-60", "type": "NDC" } ], "description": "RIFAMPIN 600 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 412.3, "gross_charge": 634.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11292", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0575-21", "type": "NDC" } ], "description": "RIFAMPIN 150 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.74, "gross_charge": 11.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112936", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50881-0005-60", "type": "NDC" } ], "description": "RUXOLITINIB 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 595.72, "gross_charge": 916.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112937", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50881-0010-60", "type": "NDC" } ], "description": "RUXOLITINIB 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 595.72, "gross_charge": 916.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112938", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50881-0015-60", "type": "NDC" } ], "description": "RUXOLITINIB 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 595.72, "gross_charge": 916.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112939", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50881-0020-60", "type": "NDC" } ], "description": "RUXOLITINIB 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 595.72, "gross_charge": 916.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-112940", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50881-0025-60", "type": "NDC" } ], "description": "RUXOLITINIB 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 595.72, "gross_charge": 916.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-113082", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00487-5901-99", "type": "NDC" } ], "description": "RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-113088", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90716", "type": "HCPCS" }, { "code": "00006-4827-01", "type": "NDC" } ], "description": "VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 563.48, "gross_charge": 866.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11349", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7252-60", "type": "NDC" } ], "description": "SENNOSIDES 8.6 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11350", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0253-01", "type": "NDC" } ], "description": "SERTRALINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11351", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0242-01", "type": "NDC" } ], "description": "SERTRALINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11359", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "27200471", "type": "HCPCS" }, { "code": "12870-0001-01", "type": "NDC" } ], "description": "SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 UN", "billing_class": "facility", "discounted_cash": 25.97, "gross_charge": 39.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11364", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0511-01", "type": "NDC" } ], "description": "SIMVASTATIN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11365", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0512-01", "type": "NDC" } ], "description": "SIMVASTATIN 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11366", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0513-90", "type": "NDC" } ], "description": "SIMVASTATIN 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11368", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2805", "type": "HCPCS" }, { "code": "72266-0248-05", "type": "NDC" } ], "description": "SINCALIDE 5 MCG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 271.6, "gross_charge": 417.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-114", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1120", "type": "HCPCS" }, { "code": "00143-9503-01", "type": "NDC" } ], "description": "ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 96.78, "gross_charge": 148.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11403", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0048-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-114047", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0755-86", "type": "NDC" } ], "description": "DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 6.86, "gross_charge": 10.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11421", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0654-01", "type": "NDC" } ], "description": "SOTALOL 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11425", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59651-0428-01", "type": "NDC" } ], "description": "SPIRONOLACTONE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11426", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59746-0217-01", "type": "NDC" } ], "description": "SPIRONOLACTONE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11441", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0738-42", "type": "NDC" } ], "description": "SUCRALFATE 100 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 10.53, "gross_charge": 16.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11500", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0549-21", "type": "NDC" } ], "description": "TEMAZEPAM 7.5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.38, "gross_charge": 17.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11507", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3105", "type": "HCPCS" }, { "code": "00143-9746-10", "type": "NDC" } ], "description": "TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 22.36, "gross_charge": 34.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11509", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00527-1311-01", "type": "NDC" } ], "description": "TERBUTALINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.6, "gross_charge": 10.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11561", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0226-05", "type": "NDC" } ], "description": "TIMOLOL MALEATE 0.25 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 11.99, "gross_charge": 18.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11562", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0514-01", "type": "NDC" } ], "description": "TIMOLOL MALEATE 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 41.21, "gross_charge": 63.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11565", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3260", "type": "HCPCS" }, { "code": "63323-0303-55", "type": "NDC" } ], "description": "TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 190.68, "gross_charge": 293.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11566", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00078-0876-01", "type": "NDC" } ], "description": "TOBRAMYCIN-DEXAMETHASONE 0.3 %-0.1 % EYE OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 GR", "billing_class": "facility", "discounted_cash": 659.23, "gross_charge": 1014.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11567", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-4031-25", "type": "NDC" } ], "description": "TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 37.5, "gross_charge": 57.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11573", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3290", "type": "HCPCS" }, { "code": "81284-0612-00", "type": "NDC" } ], "description": "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 28.34, "gross_charge": 43.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11574", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64380-0176-01", "type": "NDC" } ], "description": "TRANYLCYPROMINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.91, "gross_charge": 7.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11584", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3301", "type": "HCPCS" }, { "code": "00003-0494-20", "type": "NDC" } ], "description": "TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 23.24, "gross_charge": 35.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-116024", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9293", "type": "HCPCS" }, { "code": "50633-0210-11", "type": "NDC" } ], "description": "GLUCARPIDASE 1,000 UNIT INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 116620.98, "gross_charge": 179416.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-116027", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-4230-08", "type": "NDC" } ], "description": "IVERMECTIN 0.5 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 117 GR", "billing_class": "facility", "discounted_cash": 371.74, "gross_charge": 571.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11624", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0100-01", "type": "NDC" } ], "description": "URSODIOL 300 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.42, "gross_charge": 12.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11627", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "63323-0314-68", "type": "NDC" } ], "description": "VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 688.42, "gross_charge": 1059.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11628", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42494-0450-20", "type": "NDC" } ], "description": "VANCOMYCIN 125 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11634", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "47335-0931-40", "type": "NDC" } ], "description": "VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 47.03, "gross_charge": 72.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-116345", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "70069-0021-01", "type": "NDC" } ], "description": "DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 23.79, "gross_charge": 36.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11641", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "70199-0026-11", "type": "NDC" } ], "description": "VITAMIN A PALMITATE 50,000 UNIT/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 232.41, "gross_charge": 357.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-116596", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9306", "type": "HCPCS" }, { "code": "50242-0145-01", "type": "NDC" } ], "description": "PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 ML", "billing_class": "facility", "discounted_cash": 18443.2, "gross_charge": 28374.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11664", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-1211-01", "type": "NDC" } ], "description": "WARFARIN 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-116807", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "63323-0853-03", "type": "NDC" } ], "description": "HYDROMORPHONE (PF) 2 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 24.21, "gross_charge": 37.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11691", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3485", "type": "HCPCS" }, { "code": "49702-0213-01", "type": "NDC" } ], "description": "ZIDOVUDINE 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 109.4, "gross_charge": 168.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11692", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0107-01", "type": "NDC" } ], "description": "ZIDOVUDINE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11693", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0048-24", "type": "NDC" } ], "description": "ZIDOVUDINE 10 MG/ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 8.64, "gross_charge": 13.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11701", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0724-20", "type": "NDC" } ], "description": "ZOLPIDEM 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-117032", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9260", "type": "HCPCS" }, { "code": "61703-0408-41", "type": "NDC" } ], "description": "METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 40 ML", "billing_class": "facility", "discounted_cash": 83.62, "gross_charge": 128.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-117047", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9047", "type": "HCPCS" }, { "code": "76075-0101-01", "type": "NDC" } ], "description": "CARFILZOMIB 60 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9590.56, "gross_charge": 14754.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-117293", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61958-1201-01", "type": "NDC" } ], "description": "ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO DISOPRO 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 294.12, "gross_charge": 452.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-117352", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00456-1201-30", "type": "NDC" } ], "description": "LINACLOTIDE 145 MCG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 38.54, "gross_charge": 59.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-117353", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00456-1202-30", "type": "NDC" } ], "description": "LINACLOTIDE 290 MCG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 38.54, "gross_charge": 59.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-117592", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3430", "type": "HCPCS" }, { "code": "76329-1240-01", "type": "NDC" } ], "description": "PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 57.46, "gross_charge": 88.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119001", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90585", "type": "HCPCS" }, { "code": "00052-0603-02", "type": "NDC" } ], "description": "BCG VACCINE, LIVE (PF) 50 MG PERCUTANEOUS INJECTION SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 510.8, "gross_charge": 785.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119007", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0158-01", "type": "NDC" } ], "description": "MORPHINE ER 30 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.19, "gross_charge": 12.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119040", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00003-0893-31", "type": "NDC" } ], "description": "APIXABAN 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.22, "gross_charge": 26.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119135", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1596", "type": "HCPCS" }, { "code": "70069-0011-25", "type": "NDC" } ], "description": "GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.34, "gross_charge": 37.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119142", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "71288-0702-10", "type": "NDC" } ], "description": "ATRACURIUM 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 24.28, "gross_charge": 37.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119168", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59676-0566-30", "type": "NDC" } ], "description": "DARUNAVIR 800 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 145.05, "gross_charge": 223.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119246", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-8315-62", "type": "NDC" } ], "description": "MORPHINE ER 15 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.34, "gross_charge": 11.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119248", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-8390-23", "type": "NDC" } ], "description": "MORPHINE ER 100 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.35, "gross_charge": 25.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-11934", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00168-0357-56", "type": "NDC" } ], "description": "LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 103.74, "gross_charge": 159.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-119614", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00003-0894-31", "type": "NDC" } ], "description": "APIXABAN 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.22, "gross_charge": 26.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-120086", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9354", "type": "HCPCS" }, { "code": "50242-0088-01", "type": "NDC" } ], "description": "ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10810.48, "gross_charge": 16631.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-120087", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9354", "type": "HCPCS" }, { "code": "50242-0087-01", "type": "NDC" } ], "description": "ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17264.68, "gross_charge": 26561.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12024", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0775-01", "type": "NDC" } ], "description": "MECLIZINE 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12025", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0730-11", "type": "NDC" } ], "description": "MECLIZINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12098", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0721-01", "type": "NDC" } ], "description": "THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.43, "gross_charge": 8.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121175", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "69918-0735-02", "type": "NDC" } ], "description": "ISOPROTERENOL 0.2 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 200.75, "gross_charge": 308.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121237", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00409-4092-11", "type": "NDC" } ], "description": "CUPRIC CHLORIDE 0.4 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 115.08, "gross_charge": 177.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121241", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "48433-0230-15", "type": "NDC" } ], "description": "IODINE STRONG (LUGOLS) 5 % ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 6.96, "gross_charge": 10.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121301", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1202-07", "type": "NDC" } ], "description": "LIDOCAINE 4 % TOPICAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.68, "gross_charge": 1.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121407", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0380-01", "type": "NDC" } ], "description": "THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121432", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0665", "type": "HCPCS" }, { "code": "00409-1160-01", "type": "NDC" } ], "description": "BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 31.07, "gross_charge": 47.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121502", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00185-0842-01", "type": "NDC" } ], "description": "DEXTROAMPHETAMINE-AMPHETAMINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.88, "gross_charge": 9.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121731", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "48433-0219-40", "type": "NDC" } ], "description": "SENNOSIDES 8.8 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.34, "gross_charge": 9.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121761", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "10572-0302-01", "type": "NDC" } ], "description": "PEG-ELECTROLYTE SOLUTION 420 GRAM ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4000 ML", "billing_class": "facility", "discounted_cash": 52.0, "gross_charge": 80.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121784", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1160", "type": "HCPCS" }, { "code": "00641-6184-25", "type": "NDC" } ], "description": "DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 23.76, "gross_charge": 36.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121787", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8540", "type": "HCPCS" }, { "code": "00054-3176-44", "type": "NDC" } ], "description": "DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 63.44, "gross_charge": 97.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121831", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "63323-0852-03", "type": "NDC" } ], "description": "HYDROMORPHONE (PF) 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 28.24, "gross_charge": 43.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121872", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00409-6625-30", "type": "NDC" } ], "description": "SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 34.35, "gross_charge": 52.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121891", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "60793-0217-21", "type": "NDC" } ], "description": "THROMBIN (BOVINE) 20,000 UNIT TOPICAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 454.32, "gross_charge": 698.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121929", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "63736-0378-82", "type": "NDC" } ], "description": "BENZOCAINE 20 % TOPICAL AEROSOL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 57 GR", "billing_class": "facility", "discounted_cash": 2.44, "gross_charge": 3.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121940", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "51754-5012-01", "type": "NDC" } ], "description": "SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 39.62, "gross_charge": 60.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121940", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "63323-0083-05", "type": "NDC" } ], "description": "SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 92.3, "gross_charge": 142.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12197", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "53489-0141-01", "type": "NDC" } ], "description": "QUINIDINE GLUCONATE ER 324 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 13.94, "gross_charge": 21.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-121981", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "60793-0217-20", "type": "NDC" } ], "description": "THROMBIN (BOVINE) 20,000 UNIT TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 397.67, "gross_charge": 611.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0695-04", "type": "NDC" } ], "description": "ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 16.67, "gross_charge": 25.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122018", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1720", "type": "HCPCS" }, { "code": "00009-0825-01", "type": "NDC" } ], "description": "HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 78.36, "gross_charge": 120.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122026", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-0431-30", "type": "NDC" } ], "description": "MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.62, "gross_charge": 0.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12203", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0896-25", "type": "NDC" } ], "description": "VENLAFAXINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12204", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0159-00", "type": "NDC" } ], "description": "VENLAFAXINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12205", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0156-00", "type": "NDC" } ], "description": "VENLAFAXINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12206", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0856-01", "type": "NDC" } ], "description": "VENLAFAXINE 75 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.45, "gross_charge": 6.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12207", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0844-01", "type": "NDC" } ], "description": "VENLAFAXINE 37.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122106", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "00409-1896-20", "type": "NDC" } ], "description": "MORPHINE 50 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 82.88, "gross_charge": 127.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12211", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "50242-0100-40", "type": "NDC" } ], "description": "DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 267.18, "gross_charge": 411.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122159", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-7045-12", "type": "NDC" } ], "description": "BELLADONNA ALKALOIDS-OPIUM 16.2 MG-30 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 57.04, "gross_charge": 87.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122174", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00225-0810-47", "type": "NDC" } ], "description": "PHENYLEPHRINE 1 % NASAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 15.37, "gross_charge": 23.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1222", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0665", "type": "HCPCS" }, { "code": "00409-1159-10", "type": "NDC" } ], "description": "BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 22.26, "gross_charge": 34.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122262", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0356-01", "type": "NDC" } ], "description": "THEOPHYLLINE ER 600 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.63, "gross_charge": 10.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122267", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00555-0973-02", "type": "NDC" } ], "description": "DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.88, "gross_charge": 9.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1223", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0665", "type": "HCPCS" }, { "code": "00409-1163-18", "type": "NDC" } ], "description": "BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 22.23, "gross_charge": 34.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122308", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0628-10", "type": "NDC" } ], "description": "POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 18.46, "gross_charge": 28.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122454", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-3185-44", "type": "NDC" } ], "description": "DIAZEPAM 5 MG/ML ORAL CONCENTRATE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 5.85, "gross_charge": 9.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122471", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "72888-0125-26", "type": "NDC" } ], "description": "LIDOCAINE HCL 2 % MUCOSAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.99, "gross_charge": 10.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122552", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00472-1738-03", "type": "NDC" } ], "description": "MICONAZOLE NITRATE 200 MG VAGINAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 43.88, "gross_charge": 67.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122568", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00187-1416-16", "type": "NDC" } ], "description": "COAL TAR 1 % SHAMPOO", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 62.3, "gross_charge": 95.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-122892", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-8891-01", "type": "NDC" } ], "description": "DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.08, "gross_charge": 9.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-123", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00517-7604-25", "type": "NDC" } ], "description": "ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 13.32, "gross_charge": 20.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-123669", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "00409-1312-03", "type": "NDC" } ], "description": "HYDROMORPHONE 2 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 27.66, "gross_charge": 42.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12370", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2404", "type": "HCPCS" }, { "code": "55150-0183-10", "type": "NDC" } ], "description": "NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 50.47, "gross_charge": 77.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124096", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" }, { "code": "00002-8799-59", "type": "NDC" } ], "description": "INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 80.08, "gross_charge": 123.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124681", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90732", "type": "HCPCS" }, { "code": "00006-4837-03", "type": "NDC" } ], "description": "PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 363.74, "gross_charge": 559.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124729", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "76329-3302-01", "type": "NDC" } ], "description": "DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 48.1, "gross_charge": 74.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124737", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2020", "type": "HCPCS" }, { "code": "66794-0236-43", "type": "NDC" } ], "description": "LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 300 ML", "billing_class": "facility", "discounted_cash": 58.63, "gross_charge": 90.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124895", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2060", "type": "HCPCS" }, { "code": "00409-1985-30", "type": "NDC" } ], "description": "LORAZEPAM 2 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 23.63, "gross_charge": 36.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124908", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "00409-1283-31", "type": "NDC" } ], "description": "HYDROMORPHONE 1 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 27.3, "gross_charge": 42.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12491", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51862-0332-01", "type": "NDC" } ], "description": "ESTRADIOL 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124928", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "63323-0808-01", "type": "NDC" } ], "description": "FENTANYL (PF) 50 MCG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 24.54, "gross_charge": 37.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124935", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1050", "type": "HCPCS" }, { "code": "55150-0330-01", "type": "NDC" } ], "description": "MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 63.76, "gross_charge": 98.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-124942", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2312", "type": "HCPCS" }, { "code": "00409-1782-69", "type": "NDC" } ], "description": "NALOXONE 0.4 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 67.92, "gross_charge": 104.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12519", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9266", "type": "HCPCS" }, { "code": "72694-0954-01", "type": "NDC" } ], "description": "PEGASPARGASE 750 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 71411.34, "gross_charge": 109863.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-125366", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" }, { "code": "00169-6339-10", "type": "NDC" } ], "description": "INSULIN ASPART (U-100) 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 67.99, "gross_charge": 104.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12556", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69339-0151-17", "type": "NDC" } ], "description": "DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12580", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0394-83", "type": "NDC" } ], "description": "IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1259", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0457-73", "type": "NDC" } ], "description": "CAFFEINE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-125923", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0280", "type": "HCPCS" }, { "code": "00409-5922-01", "type": "NDC" } ], "description": "AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 45.56, "gross_charge": 70.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-125938", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0166", "type": "HCPCS" }, { "code": "54288-0120-01", "type": "NDC" } ], "description": "EPINEPHRINE 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 22.65, "gross_charge": 34.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1262", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00517-2502-01", "type": "NDC" } ], "description": "CAFFEINE-SODIUM BENZOATE 250 MG/ML(125 MG/ML CAFFEINE) INJECTION SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 73.35, "gross_charge": 112.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-126678", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1580", "type": "HCPCS" }, { "code": "00338-0507-48", "type": "NDC" } ], "description": "GENTAMICIN 120 MG/100 ML IN SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 45.01, "gross_charge": 69.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-126797", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "58980-0012-05", "type": "NDC" } ], "description": "BACITRACIN ZINC 500 UNIT-POLYMYXIN B 10,000 UNIT/GRAM TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 2.08, "gross_charge": 3.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12724", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69097-0859-07", "type": "NDC" } ], "description": "TERBINAFINE HCL 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127257", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00487-9901-30", "type": "NDC" } ], "description": "ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.93, "gross_charge": 6.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127625", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2590", "type": "HCPCS" }, { "code": "70004-0085-44", "type": "NDC" } ], "description": "OXYTOCIN 30 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 93.4, "gross_charge": 143.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127631", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "70092-1019-15", "type": "NDC" } ], "description": "CEFAZOLIN 2 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 74.42, "gross_charge": 114.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127668", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1630", "type": "HCPCS" }, { "code": "76045-0737-01", "type": "NDC" } ], "description": "HALOPERIDOL LACTATE 5 MG/ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 24.41, "gross_charge": 37.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127673", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00121-4722-15", "type": "NDC" } ], "description": "SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 2.44, "gross_charge": 3.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127673", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00121-0722-08", "type": "NDC" } ], "description": "SENNA LEAF EXTRACT 176 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 237 ML", "billing_class": "facility", "discounted_cash": 7.12, "gross_charge": 10.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127698", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00225-0525-47", "type": "NDC" } ], "description": "SODIUM CHLORIDE-ALOE VERA NASAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14.1 GR", "billing_class": "facility", "discounted_cash": 12.19, "gross_charge": 18.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127778", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00884-6297-30", "type": "NDC" } ], "description": "PHENOL 89 % TOPICAL SWAB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.54, "gross_charge": 17.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127851", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0592", "type": "HCPCS" }, { "code": "42023-0179-01", "type": "NDC" } ], "description": "BUPRENORPHINE HCL 0.3 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 62.79, "gross_charge": 96.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127883", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "80681-0134-00", "type": "NDC" } ], "description": "VITAMIN E (DL, ACETATE) 45 MG (100 UNIT) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-127974", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "31604-0017-96", "type": "NDC" } ], "description": "MULTIVITAMIN-MINERALS-FOLIC ACID-LUTEIN 0.4 MG-250 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128022", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2175", "type": "HCPCS" }, { "code": "00409-1176-30", "type": "NDC" } ], "description": "MEPERIDINE (PF) 25 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 40.43, "gross_charge": 62.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128032", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "20555-0025-00", "type": "NDC" } ], "description": "CALCIUM 250 MG (AS CARBONATE)-VITAMIN D3 3.125 MCG (125 UNIT) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128039", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7050", "type": "HCPCS" }, { "code": "00338-0553-18", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 46.12, "gross_charge": 70.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128039", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7050", "type": "HCPCS" }, { "code": "00409-7101-02", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 47.06, "gross_charge": 72.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128039", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7050", "type": "HCPCS" }, { "code": "00338-0553-11", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 46.12, "gross_charge": 70.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128040", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7060", "type": "HCPCS" }, { "code": "00338-0551-18", "type": "NDC" } ], "description": "DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 46.12, "gross_charge": 70.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128067", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9030", "type": "HCPCS" }, { "code": "00052-0602-02", "type": "NDC" } ], "description": "BCG LIVE 50 MG INTRAVESICAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 509.24, "gross_charge": 783.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128087", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "10122-0510-03", "type": "NDC" } ], "description": "PORACTANT ALFA 240 MG/3 ML INTRATRACHEAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 2187.7, "gross_charge": 3365.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128157", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7198", "type": "HCPCS" }, { "code": "64193-0425-02", "type": "NDC" } ], "description": "ANTI-INHIBITOR COAGULANT COMPLX 1,750 UNIT-3,250 UNIT INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14073.93, "gross_charge": 21652.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128178", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "63323-0276-02", "type": "NDC" } ], "description": "HEPARIN, PORCINE (PF) 1,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 37.38, "gross_charge": 57.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128277", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "63323-0208-05", "type": "NDC" } ], "description": "LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 26.1, "gross_charge": 40.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128535", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57896-0116-03", "type": "NDC" } ], "description": "METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 85 GR", "billing_class": "facility", "discounted_cash": 1.66, "gross_charge": 2.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128574", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0166", "type": "HCPCS" }, { "code": "54288-0103-10", "type": "NDC" } ], "description": "EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 24.73, "gross_charge": 38.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12858", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "40565-0122-56", "type": "NDC" } ], "description": "CADEXOMER IODINE 0.9 % TOPICAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 GR", "billing_class": "facility", "discounted_cash": 34.26, "gross_charge": 52.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128662", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90371", "type": "HCPCS" }, { "code": "13533-0636-05", "type": "NDC" } ], "description": "HEPATITIS B IMMUNE GLOBULIN 220 UNIT/ML (5 ML) INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 2184.2, "gross_charge": 3360.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128663", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90371", "type": "HCPCS" }, { "code": "13533-0636-03", "type": "NDC" } ], "description": "HEPATITIS B IMMUNE GLOBULIN 110 UNIT/0.5 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 271.83, "gross_charge": 418.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-128822", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90744", "type": "HCPCS" }, { "code": "58160-0820-52", "type": "NDC" } ], "description": "HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 109.69, "gross_charge": 168.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129043", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "76045-0010-01", "type": "NDC" } ], "description": "HYDROMORPHONE (PF) 2 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 25.77, "gross_charge": 39.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12933", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7507", "type": "HCPCS" }, { "code": "68084-0450-11", "type": "NDC" } ], "description": "TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129339", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1580", "type": "HCPCS" }, { "code": "63323-0173-02", "type": "NDC" } ], "description": "GENTAMICIN SULFATE (PEDIATRIC) (PF) 20 MG/2 ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 27.66, "gross_charge": 42.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12934", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7507", "type": "HCPCS" }, { "code": "55111-0527-01", "type": "NDC" } ], "description": "TACROLIMUS 5 MG CAPSULE, IMMEDIATE-RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.01, "gross_charge": 9.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-12935", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7525", "type": "HCPCS" }, { "code": "00469-3016-01", "type": "NDC" } ], "description": "TACROLIMUS 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 829.72, "gross_charge": 1276.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129393", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "60793-0215-05", "type": "NDC" } ], "description": "THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 107.51, "gross_charge": 165.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129448", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1308", "type": "HCPCS" }, { "code": "00641-6022-01", "type": "NDC" } ], "description": "FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.23, "gross_charge": 34.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129504", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3475", "type": "HCPCS" }, { "code": "63323-0106-02", "type": "NDC" } ], "description": "MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 46.93, "gross_charge": 72.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129578", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3475", "type": "HCPCS" }, { "code": "63323-0106-15", "type": "NDC" } ], "description": "MAGNESIUM SULFATE 20 GRAM/500 ML (4 %) IN WATER INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 47.74, "gross_charge": 73.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129579", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3475", "type": "HCPCS" }, { "code": "63323-0106-10", "type": "NDC" } ], "description": "MAGNESIUM SULFATE 40 GRAM/1,000 ML (4 %) IN WATER INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 51.8, "gross_charge": 79.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129648", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90700", "type": "HCPCS" }, { "code": "49281-0286-58", "type": "NDC" } ], "description": "DIPH,PERTUS(ACEL),TET PEDI (PF) 15 LF UNIT-10 MCG-5 LF/0.5 ML IM SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 93.63, "gross_charge": 144.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129705", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0275-62", "type": "NDC" } ], "description": "PHENYTOIN 100 MG/4 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 13.39, "gross_charge": 20.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129747", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90632", "type": "HCPCS" }, { "code": "00006-4841-41", "type": "NDC" } ], "description": "HEPATITIS A VIRUS VACCINE (PF) 50 UNIT/ML INTRAMUSCULAR SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 237.58, "gross_charge": 365.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129749", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90744", "type": "HCPCS" }, { "code": "00006-4981-01", "type": "NDC" } ], "description": "HEPATITIS B VIRUS VACCINE RECOMB (PF) 5 MCG/0.5 ML INTRAMUSCULAR SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 87.72, "gross_charge": 134.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129774", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1670", "type": "HCPCS" }, { "code": "13533-0634-02", "type": "NDC" } ], "description": "TETANUS IMMUNE GLOBULIN (PF) 250 UNIT/ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 1765.86, "gross_charge": 2716.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129897", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "00338-0433-04", "type": "NDC" } ], "description": "HEPARIN (PORCINE) (PF) 2,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1299", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-4766-05", "type": "NDC" } ], "description": "CALCIUM 500 MG/5 ML (AS CALCIUM CARB 1,250 MG/5 ML) ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 5.4, "gross_charge": 8.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129903", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00065-0509-35", "type": "NDC" } ], "description": "WHITE PETROLATUM-MINERAL OIL 94 %-3 % EYE OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 GR", "billing_class": "facility", "discounted_cash": 18.04, "gross_charge": 27.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129965", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "48582-0001-55", "type": "NDC" } ], "description": "SALIVA STIMULANT COMBINATION NO.3 ORAL MUCOSAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 44.3 ML", "billing_class": "facility", "discounted_cash": 19.73, "gross_charge": 30.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129971", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "76329-3011-05", "type": "NDC" } ], "description": "LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 18.23, "gross_charge": 28.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-129974", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9370", "type": "HCPCS" }, { "code": "61703-0309-25", "type": "NDC" } ], "description": "VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 79.69, "gross_charge": 122.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1300", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-1883-61", "type": "NDC" } ], "description": "CALCIUM 500 MG (AS CALCIUM CARBONATE 1,250 MG) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130004", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9000", "type": "HCPCS" }, { "code": "25021-0207-25", "type": "NDC" } ], "description": "DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 75.89, "gross_charge": 116.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130005", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9000", "type": "HCPCS" }, { "code": "00143-9088-01", "type": "NDC" } ], "description": "DOXORUBICIN 10 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 68.41, "gross_charge": 105.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130088", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1265", "type": "HCPCS" }, { "code": "00409-9104-20", "type": "NDC" } ], "description": "DOPAMINE 400 MG/10 ML (40 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 27.92, "gross_charge": 42.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130165", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "71286-3022-01", "type": "NDC" } ], "description": "KETAMINE 50 MG/5 ML (10 MG/ML) IN 0.9 % SODIUM CHLORIDE IV SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 40.4, "gross_charge": 62.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130186", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "63323-0810-00", "type": "NDC" } ], "description": "FENTANYL (PF) 100 MCG/2 ML (50 MCG/ML) INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 24.12, "gross_charge": 37.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130190", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0249-77", "type": "NDC" } ], "description": "LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.82, "gross_charge": 10.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130249", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "46581-0675-09", "type": "NDC" } ], "description": "METHYL SALICYLATE 10 %-MENTHOL 3 % TOPICAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.78, "gross_charge": 1.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130445", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00574-0302-16", "type": "NDC" } ], "description": "COMPOUNDING VEHICLE SUGAR-FREE NO.9 ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 49.4, "gross_charge": 76.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130472", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42192-0329-01", "type": "NDC" } ], "description": "THYROID (PORK) 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.29, "gross_charge": 6.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130473", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42192-0330-01", "type": "NDC" } ], "description": "THYROID (PORK) 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.45, "gross_charge": 6.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1306", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0618", "type": "HCPCS" }, { "code": "64253-0900-36", "type": "NDC" } ], "description": "CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 33.44, "gross_charge": 51.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130647", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0740-24", "type": "NDC" } ], "description": "ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10.15 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13073", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "75834-0159-01", "type": "NDC" } ], "description": "VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130755", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0039-33", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 36.82, "gross_charge": 56.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130756", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0047-22", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 45.92, "gross_charge": 70.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130757", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0003-02", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SOD SUCC (PF) 500 MG/4 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 163.25, "gross_charge": 251.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130758", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0018-20", "type": "NDC" } ], "description": "METHYLPREDNISOLONE SOD SUCC (PF) 1,000 MG/8 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 205.86, "gross_charge": 316.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1308", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "80681-0140-00", "type": "NDC" } ], "description": "CALCIUM 200 MG (AS CALCIUM CITRATE 950 MG) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130805", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00501-3400-02", "type": "NDC" } ], "description": "ZINC OXIDE-COD LIVER OIL 40 % TOPICAL PASTE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 57 GR", "billing_class": "facility", "discounted_cash": 14.92, "gross_charge": 22.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130841", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0003-75", "type": "NDC" } ], "description": "FENTANYL (PF) 300 MCG/30 ML (10 MCG/ML) IN 0.9 % NACL IV PCA SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130864", "type": "CDM" }, { "code": "258", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "00000-0016-03", "type": "NDC" } ], "description": "HYDROMORPHONE (PF) 0.2 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 35.78, "gross_charge": 55.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13089", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0512-02", "type": "NDC" } ], "description": "LISINOPRIL 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.06, "gross_charge": 4.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130942", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1720", "type": "HCPCS" }, { "code": "00009-0016-12", "type": "NDC" } ], "description": "HYDROCORTISONE SOD SUCCINATE (PF) 500 MG/4 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 284.24, "gross_charge": 437.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130943", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1720", "type": "HCPCS" }, { "code": "00009-0013-05", "type": "NDC" } ], "description": "HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 154.9, "gross_charge": 238.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-130944", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1720", "type": "HCPCS" }, { "code": "00009-0011-04", "type": "NDC" } ], "description": "HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 85.83, "gross_charge": 132.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131038", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69367-0267-01", "type": "NDC" } ], "description": "PRENATAL VITAMINS WITH CALCIUM NO.72-IRON 27 MG-FOLIC ACID 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131039", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00000-0102-80", "type": "NDC" } ], "description": "VANCOMYCIN 1.25 GRAM/250 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 58.63, "gross_charge": 90.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131041", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00000-0102-81", "type": "NDC" } ], "description": "VANCOMYCIN 1.75 GRAM/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 64.09, "gross_charge": 98.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131042", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00000-0016-88", "type": "NDC" } ], "description": "VANCOMYCIN 2 GRAM/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 66.79, "gross_charge": 102.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131067", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0957-10", "type": "NDC" } ], "description": "PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 23.04, "gross_charge": 35.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131069", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0330", "type": "HCPCS" }, { "code": "73177-0116-03", "type": "NDC" } ], "description": "SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 26.62, "gross_charge": 40.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131124", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "77333-0934-10", "type": "NDC" } ], "description": "THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131187", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "24571-0111-06", "type": "NDC" } ], "description": "BICARB HEMODIALYSIS SOLN WITHOUT CALCIUM NO 16 POT 4 MEQ-MAG 1.5 MEQ/L", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 45.86, "gross_charge": 70.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13133", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0215-01", "type": "NDC" } ], "description": "VALACYCLOVIR 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.49, "gross_charge": 8.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131337", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1561", "type": "HCPCS" }, { "code": "13533-0800-20", "type": "NDC" } ], "description": "IMMUNE GLOBU G 5 GRAM/50 ML(10 %)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 954.95, "gross_charge": 1469.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131338", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1561", "type": "HCPCS" }, { "code": "13533-0800-71", "type": "NDC" } ], "description": "IMMUNE GLOB G 10 GRAM/100 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 1871.68, "gross_charge": 2879.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131339", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1561", "type": "HCPCS" }, { "code": "13533-0800-24", "type": "NDC" } ], "description": "IMMUNE GLOB G 20 GRAM/200 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 3705.13, "gross_charge": 5700.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131353", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1163", "type": "HCPCS" }, { "code": "63037-0117-05", "type": "NDC" } ], "description": "DILTIAZEM HCL 125 MG/125 ML (1 MG/ML) IN SOD CHLORIDE,ISO-OSM IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 125 ML", "billing_class": "facility", "discounted_cash": 92.66, "gross_charge": 142.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131372", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00065-0741-14", "type": "NDC" } ], "description": "TETRACAINE HCL (PF) 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 38.77, "gross_charge": 59.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131390", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "70121-1722-09", "type": "NDC" } ], "description": "POTASSIUM PHOSPHATE 15 MMOL/250 ML IN 0.9 % SODIUM CHLORIDE IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 2036.97, "gross_charge": 3133.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131439", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "00000-0007-65", "type": "NDC" } ], "description": "SODIUM BICARBONATE 150 MEQ/1,000 ML IN DEXTROSE 5 % INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 87.23, "gross_charge": 134.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131557", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2354", "type": "HCPCS" }, { "code": "67457-0245-00", "type": "NDC" } ], "description": "OCTREOTIDE ACETATE 100 MCG/ML (1 ML) INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 37.21, "gross_charge": 57.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131616", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" }, { "code": "00074-3642-03", "type": "NDC" } ], "description": "LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 519.94, "gross_charge": 799.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131803", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0013-64", "type": "NDC" } ], "description": "HYDROMORPHONE 15 MG/30 ML (0.5 MG/ML) IN 0.9 % NACL IV PCA SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 72.67, "gross_charge": 111.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13184", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0292-01", "type": "NDC" } ], "description": "VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.13, "gross_charge": 6.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131883", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00005-4461-19", "type": "NDC" } ], "description": "MULTIVITAMIN-MINERAL-FOLIC ACID 400 MCG-LUTEIN 250 MCG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-131987", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0315-25", "type": "NDC" } ], "description": "NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 45.01, "gross_charge": 69.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132015", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "70092-1558-44", "type": "NDC" } ], "description": "LABETALOL 20 MG/4 ML (5 MG/ML) INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 35.33, "gross_charge": 54.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132049", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-4675-00", "type": "NDC" } ], "description": "VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132058", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1350-00", "type": "NDC" } ], "description": "VALPROIC ACID (AS SODIUM SALT) 500 MG/10 ML (10 ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 5.2, "gross_charge": 8.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132075", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "73177-0105-01", "type": "NDC" } ], "description": "MORPHINE (PF) 2 MG/2 ML(1 MG/ML) IN 0.9% SODIUM CHLORIDE IV SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 30.42, "gross_charge": 46.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132167", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2212", "type": "HCPCS" }, { "code": "65649-0551-07", "type": "NDC" } ], "description": "METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 362.86, "gross_charge": 558.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132172", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "54643-5649-01", "type": "NDC" } ], "description": "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 36.69, "gross_charge": 56.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132172", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "54643-5650-02", "type": "NDC" } ], "description": "MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 154.41, "gross_charge": 237.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132288", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "66794-0019-10", "type": "NDC" } ], "description": "ISOFLURANE 99.9 % INHALATION LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 44.26, "gross_charge": 68.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132321", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0979-30", "type": "NDC" } ], "description": "MORPHINE (PF) 30 MG/30 ML(1 MG/ML) IN 0.9% SOD.CHLORIDE IV PCA SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 50.47, "gross_charge": 77.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132326", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0979-02", "type": "NDC" } ], "description": "MORPHINE (PF) 2 MG/2 ML (1 MG/ML) IN 0.9% SODIUM CHLORIDE INJ SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 29.15, "gross_charge": 44.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132405", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "00000-0112-93", "type": "NDC" } ], "description": "HEPARIN (PORCINE) 5,000 UNIT/1,000 ML IN 0.9 % SODIUM CHLORIDE IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 41.02, "gross_charge": 63.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132437", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0597", "type": "HCPCS" }, { "code": "63833-0835-01", "type": "NDC" } ], "description": "C1 ESTERASE INHIBITOR 500 UNIT (10 ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11865.78, "gross_charge": 18255.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132533", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90744", "type": "HCPCS" }, { "code": "00006-4093-02", "type": "NDC" } ], "description": "HEPATITIS B VIRUS VACCINE RECMB(PF) 5 MCG/0.5 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 87.72, "gross_charge": 134.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132556", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "60793-0705-05", "type": "NDC" } ], "description": "THROMBIN (BOVINE) 5,000 UNIT TOPICAL SPRAY SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 116.19, "gross_charge": 178.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132557", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "60793-0217-22", "type": "NDC" } ], "description": "THROMBIN (BOVINE) 20,000 UNIT TOPICAL SPRAY SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 454.32, "gross_charge": 698.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132558", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "60793-0205-05", "type": "NDC" } ], "description": "THROMBIN (BOVINE) 5,000 UNIT NASAL SPRAY SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 124.57, "gross_charge": 191.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132720", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42192-0608-40", "type": "NDC" } ], "description": "GABAPENTIN 300 MG/6 ML (6 ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 10.04, "gross_charge": 15.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132783", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1325", "type": "HCPCS" }, { "code": "62756-0059-40", "type": "NDC" } ], "description": "EPOPROSTENOL 0.5 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 74.07, "gross_charge": 113.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132830", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7510", "type": "HCPCS" }, { "code": "00121-4759-05", "type": "NDC" } ], "description": "PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (5 ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 20.93, "gross_charge": 32.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-132918", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "81033-0501-15", "type": "NDC" } ], "description": "MULTIVIT-MINS-FERROUS GLUCONATE 9 MG IRON/15 ML (15 ML) ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 1.27, "gross_charge": 1.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-133072", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "51552-1345-01", "type": "NDC" } ], "description": "LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL SOLUTION KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 8.45, "gross_charge": 13.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13369", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62756-0522-69", "type": "NDC" } ], "description": "SUMATRIPTAN 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1350", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-2525-25", "type": "NDC" } ], "description": "CAPSAICIN 0.025 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 GR", "billing_class": "facility", "discounted_cash": 13.78, "gross_charge": 21.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1355", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0479-11", "type": "NDC" } ], "description": "CARBAMAZEPINE 100 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1356", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62135-0867-59", "type": "NDC" } ], "description": "CARBAMAZEPINE 200 MG/10 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 183.5, "gross_charge": 282.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1357", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-4005-01", "type": "NDC" } ], "description": "CARBAMAZEPINE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13691", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1950", "type": "HCPCS" }, { "code": "00074-3641-03", "type": "NDC" } ], "description": "LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4799.28, "gross_charge": 7383.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13818", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24385-0060-03", "type": "NDC" } ], "description": "BACITRACIN ZINC 500 UNIT/GRAM TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 28.4 GR", "billing_class": "facility", "discounted_cash": 0.75, "gross_charge": 1.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1395", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69584-0111-10", "type": "NDC" } ], "description": "CARISOPRODOL 350 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13981", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0318-01", "type": "NDC" } ], "description": "LAMOTRIGINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-13982", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0319-01", "type": "NDC" } ], "description": "LAMOTRIGINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14087", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-0484-62", "type": "NDC" } ], "description": "ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.47, "gross_charge": 9.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14132", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0465-64", "type": "NDC" } ], "description": "KETOCONAZOLE 2 % SHAMPOO", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 120 ML", "billing_class": "facility", "discounted_cash": 41.89, "gross_charge": 64.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14203", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9390", "type": "HCPCS" }, { "code": "25021-0204-01", "type": "NDC" } ], "description": "VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 73.38, "gross_charge": 112.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14232", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57237-0149-35", "type": "NDC" } ], "description": "FLUCONAZOLE 10 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 9.13, "gross_charge": 14.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14233", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57237-0150-35", "type": "NDC" } ], "description": "FLUCONAZOLE 40 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.25 ML", "billing_class": "facility", "discounted_cash": 5.78, "gross_charge": 8.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14266", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0693-11", "type": "NDC" } ], "description": "LAMOTRIGINE 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1445", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0690", "type": "HCPCS" }, { "code": "00143-9262-25", "type": "NDC" } ], "description": "CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.24, "gross_charge": 35.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1446", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0690", "type": "HCPCS" }, { "code": "00143-9261-01", "type": "NDC" } ], "description": "CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34.38, "gross_charge": 52.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14471", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69315-0304-10", "type": "NDC" } ], "description": "DORZOLAMIDE 2 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 90.8, "gross_charge": 139.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1448", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0690", "type": "HCPCS" }, { "code": "00143-9923-90", "type": "NDC" } ], "description": "CEFAZOLIN 500 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.25, "gross_charge": 38.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14626", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0293-01", "type": "NDC" } ], "description": "VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14632", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0795-01", "type": "NDC" } ], "description": "TRAMADOL 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.62, "gross_charge": 8.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14643", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0885", "type": "HCPCS" }, { "code": "59676-0320-04", "type": "NDC" } ], "description": "EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 936.23, "gross_charge": 1440.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14702", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0005-64", "type": "NDC" } ], "description": "ACETIC ACID (BULK) 5 % LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 16.22, "gross_charge": 24.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14702", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "51552-0055-06", "type": "NDC" } ], "description": "ACETIC ACID (BULK) 5 % LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 58.73, "gross_charge": 90.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14719", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0143-01", "type": "NDC" } ], "description": "METFORMIN 850 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14792", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0775-25", "type": "NDC" } ], "description": "TIZANIDINE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.16, "gross_charge": 6.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14793", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0252-02", "type": "NDC" } ], "description": "TIZANIDINE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14823", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0346-11", "type": "NDC" } ], "description": "LOSARTAN 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14824", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0347-01", "type": "NDC" } ], "description": "LOSARTAN 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14825", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70700-0268-99", "type": "NDC" } ], "description": "FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 133.18, "gross_charge": 204.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14845", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1265", "type": "HCPCS" }, { "code": "00338-1007-02", "type": "NDC" } ], "description": "DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 64.77, "gross_charge": 99.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14847", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24385-0441-64", "type": "NDC" } ], "description": "DOXYLAMINE SUCCINATE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14868", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2002", "type": "HCPCS" }, { "code": "00338-0409-03", "type": "NDC" } ], "description": "LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14870", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2004", "type": "HCPCS" }, { "code": "00409-3177-01", "type": "NDC" } ], "description": "LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 21.55, "gross_charge": 33.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14953", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0629-21", "type": "NDC" } ], "description": "ATOVAQUONE 750 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 19.47, "gross_charge": 29.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14979", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-3977-03", "type": "NDC" } ], "description": "WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 27.4, "gross_charge": 42.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-14983", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-1752-50", "type": "NDC" } ], "description": "BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 24.08, "gross_charge": 37.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15065", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16837-0872-30", "type": "NDC" } ], "description": "FAMOTIDINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15113", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7517", "type": "HCPCS" }, { "code": "51079-0721-20", "type": "NDC" } ], "description": "MYCOPHENOLATE MOFETIL 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.84, "gross_charge": 5.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15119", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "66794-0022-25", "type": "NDC" } ], "description": "SEVOFLURANE 99.97 % INHALATION LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 175.14, "gross_charge": 269.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15327", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0146-36", "type": "NDC" } ], "description": "SUMATRIPTAN 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15328", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "55111-0292-36", "type": "NDC" } ], "description": "SUMATRIPTAN 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15370", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0640", "type": "HCPCS" }, { "code": "63323-0631-10", "type": "NDC" } ], "description": "LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 74.68, "gross_charge": 114.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15426", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0640", "type": "HCPCS" }, { "code": "63323-0710-50", "type": "NDC" } ], "description": "LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 70.2, "gross_charge": 108.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1562", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00395-2662-16", "type": "NDC" } ], "description": "CHERRY FLAVOR (BULK) ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 480 ML", "billing_class": "facility", "discounted_cash": 25.54, "gross_charge": 39.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15706", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1190-00", "type": "NDC" } ], "description": "SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 7.48, "gross_charge": 11.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15723", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0725-15", "type": "NDC" } ], "description": "SOTALOL 120 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15738", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0823-06", "type": "NDC" } ], "description": "CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.7 ML", "billing_class": "facility", "discounted_cash": 193.24, "gross_charge": 297.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15746", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "47335-0485-88", "type": "NDC" } ], "description": "BICALUTAMIDE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15747", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0854-01", "type": "NDC" } ], "description": "CARVEDILOL 6.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15748", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7308-61", "type": "NDC" } ], "description": "CARVEDILOL 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15749", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7307-61", "type": "NDC" } ], "description": "CARVEDILOL 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15797", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "Q0144", "type": "HCPCS" }, { "code": "00093-2026-31", "type": "NDC" } ], "description": "AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 8.35, "gross_charge": 12.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15847", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "00338-0431-03", "type": "NDC" } ], "description": "HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 50.47, "gross_charge": 77.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15848", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "63323-0518-01", "type": "NDC" } ], "description": "HEPARIN (PORCINE) 25,000 UNIT/500 ML IN 0.45 % SODIUM CHLORIDE IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 41.05, "gross_charge": 63.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15849", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "63323-0517-01", "type": "NDC" } ], "description": "HEPARIN (PORCINE) 25,000 UNIT/250 ML IN 0.45 % SODIUM CHLORIDE IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 60.0, "gross_charge": 92.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15852", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "00409-3815-12", "type": "NDC" } ], "description": "MORPHINE (PF) 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 27.72, "gross_charge": 42.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15859", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2305", "type": "HCPCS" }, { "code": "00338-1049-02", "type": "NDC" } ], "description": "NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 83.14, "gross_charge": 127.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15880", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0720-21", "type": "NDC" } ], "description": "LAMIVUDINE 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.02, "gross_charge": 18.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15881", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57237-0274-24", "type": "NDC" } ], "description": "LAMIVUDINE 10 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 7.25, "gross_charge": 11.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15895", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64380-0759-06", "type": "NDC" } ], "description": "ACARBOSE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15950", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "39328-0063-25", "type": "NDC" } ], "description": "SODIUM HYPOCHLORITE 0.25 % SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 37.8, "gross_charge": 58.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15956", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2004", "type": "HCPCS" }, { "code": "00409-1209-01", "type": "NDC" } ], "description": "LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 23.5, "gross_charge": 36.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15985", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2004", "type": "HCPCS" }, { "code": "63323-0487-37", "type": "NDC" } ], "description": "LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.68, "gross_charge": 34.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-15996", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00527-1927-36", "type": "NDC" } ], "description": "METHADONE 10 MG/ML ORAL CONCENTRATE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 6.04, "gross_charge": 9.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16005", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0075-21", "type": "NDC" } ], "description": "TRETINOIN (ANTINEOPLASTIC) 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 42.96, "gross_charge": 66.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16014", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0811-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/L-LACTATED RINGERS-5 % DEXTROSE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16050", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0108-38", "type": "NDC" } ], "description": "GLUCOSE 4 GRAM CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16053", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0732-11", "type": "NDC" } ], "description": "DESMOPRESSIN 0.2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.7, "gross_charge": 10.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16124", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "67877-0286-60", "type": "NDC" } ], "description": "RILUZOLE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.1, "gross_charge": 6.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16162", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3475", "type": "HCPCS" }, { "code": "00338-1709-40", "type": "NDC" } ], "description": "MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 42.02, "gross_charge": 64.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16169", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00074-4382-20", "type": "NDC" } ], "description": "CISATRACURIUM CONCENTRATE 10 MG/ML (ICU USE ONLY) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 955.86, "gross_charge": 1470.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16205", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0112-21", "type": "NDC" } ], "description": "ANASTROZOLE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.52, "gross_charge": 6.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16218", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-3120-41", "type": "NDC" } ], "description": "CALCITRIOL 1 MCG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 5.46, "gross_charge": 8.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16254", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9202", "type": "HCPCS" }, { "code": "70720-0951-30", "type": "NDC" } ], "description": "GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10151.76, "gross_charge": 15618.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16299", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-5354-31", "type": "NDC" } ], "description": "DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 28 GR", "billing_class": "facility", "discounted_cash": 1.01, "gross_charge": 1.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1635", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2401", "type": "HCPCS" }, { "code": "63323-0478-27", "type": "NDC" } ], "description": "CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 85.48, "gross_charge": 131.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16356", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0326-01", "type": "NDC" } ], "description": "GLIMEPIRIDE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16369", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0692", "type": "HCPCS" }, { "code": "00409-9566-10", "type": "NDC" } ], "description": "CEFEPIME 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.95, "gross_charge": 49.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16371", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0692", "type": "HCPCS" }, { "code": "60505-6147-04", "type": "NDC" } ], "description": "CEFEPIME 2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 63.99, "gross_charge": 98.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164645", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0241-20", "type": "NDC" } ], "description": "SODIUM GLYCEROPHOSPHATE 1 MMOL/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 56.0, "gross_charge": 86.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164705", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "50458-0140-30", "type": "NDC" } ], "description": "CANAGLIFLOZIN 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 40.46, "gross_charge": 62.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164706", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "50458-0141-30", "type": "NDC" } ], "description": "CANAGLIFLOZIN 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 40.46, "gross_charge": 62.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164749", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63304-0192-30", "type": "NDC" } ], "description": "DESVENLAFAXINE ER 100 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.37, "gross_charge": 15.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164810", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-1660-50", "type": "NDC" } ], "description": "DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 63.8, "gross_charge": 98.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164812", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-1174-10", "type": "NDC" } ], "description": "DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 76.86, "gross_charge": 118.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164827", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0143-97", "type": "NDC" } ], "description": "TRACE ELEMENTS #1 5.33 MCG-0.34 MG-0.54 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 65.16, "gross_charge": 100.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-164887", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00023-4491-30", "type": "NDC" } ], "description": "CARBOXYMETHYL 0.5 %-GLYCERIN 1 %-POLYSORB 80 0.5 %-PF EYE DROPPERETTE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1649", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3230", "type": "HCPCS" }, { "code": "00641-1397-31", "type": "NDC" } ], "description": "CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 104.13, "gross_charge": 160.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165024", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00173-0859-10", "type": "NDC" } ], "description": "FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.76, "gross_charge": 24.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165106", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00054-0622-63", "type": "NDC" } ], "description": "DICYCLOMINE 10 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 8.58, "gross_charge": 13.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165151", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0423-08", "type": "NDC" } ], "description": "CEFIXIME 400 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.54, "gross_charge": 39.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165188", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2710", "type": "HCPCS" }, { "code": "00641-6150-10", "type": "NDC" } ], "description": "NEOSTIGMINE METHYLSULFATE 0.5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 27.43, "gross_charge": 42.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165189", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2710", "type": "HCPCS" }, { "code": "00641-6149-01", "type": "NDC" } ], "description": "NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 27.43, "gross_charge": 42.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165225", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00032-3016-13", "type": "NDC" } ], "description": "LIPASE-PROTEASE-AMYLASE (PORK)36,000-114,000-180K UNIT CAPSULE,DEL REL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27.27, "gross_charge": 41.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1653", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0419-11", "type": "NDC" } ], "description": "CHLORPROMAZINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.54, "gross_charge": 11.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165368", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00942-0641-04", "type": "NDC" } ], "description": "DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 730 MG/100 ML SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 59.05, "gross_charge": 90.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1654", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0452-11", "type": "NDC" } ], "description": "CHLORPROMAZINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14.07, "gross_charge": 21.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165471", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00224-1901-00", "type": "NDC" } ], "description": "PSYLLIUM HUSK 6 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.29, "gross_charge": 0.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-165473", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1439", "type": "HCPCS" }, { "code": "00517-0650-01", "type": "NDC" } ], "description": "FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 3375.84, "gross_charge": 5193.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1656", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0430-01", "type": "NDC" } ], "description": "CHLORPROMAZINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.84, "gross_charge": 13.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1661", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0058-20", "type": "NDC" } ], "description": "CHLORTHALIDONE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.34, "gross_charge": 9.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16632", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68382-0097-05", "type": "NDC" } ], "description": "PAROXETINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.06, "gross_charge": 4.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16633", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68382-0001-16", "type": "NDC" } ], "description": "PAROXETINE 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166481", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "67684-1901-02", "type": "NDC" } ], "description": "ETHIODIZED OIL 480 MG IODINE/ML FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 3964.06, "gross_charge": 6098.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166500", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" }, { "code": "00409-2308-49", "type": "NDC" } ], "description": "MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.28, "gross_charge": 37.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166501", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" }, { "code": "00409-0001-25", "type": "NDC" } ], "description": "MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.1, "gross_charge": 34.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166510", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3489", "type": "HCPCS" }, { "code": "25021-0826-67", "type": "NDC" } ], "description": "ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 98.38, "gross_charge": 151.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166519", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7195", "type": "HCPCS" }, { "code": "58394-0634-03", "type": "NDC" } ], "description": "COAGULATION FACTOR IX (RECOMB) 500 UNIT INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2840.5, "gross_charge": 4370.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166520", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7195", "type": "HCPCS" }, { "code": "58394-0635-03", "type": "NDC" } ], "description": "COAGULATION FACTOR IX (RECOMB) 1,000 UNIT INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5659.58, "gross_charge": 8707.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166521", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7195", "type": "HCPCS" }, { "code": "58394-0636-03", "type": "NDC" } ], "description": "COAGULATION FACTOR IX (RECOMB) 2,000 UNIT INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11297.72, "gross_charge": 17381.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166522", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7195", "type": "HCPCS" }, { "code": "58394-0637-03", "type": "NDC" } ], "description": "COAGULATION FACTOR IX (RECOMB) 3,000 UNIT INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16935.91, "gross_charge": 26055.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166524", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7300", "type": "HCPCS" }, { "code": "59365-5128-01", "type": "NDC" } ], "description": "COPPER 380 SQUARE MM INTRAUTERINE DEVICE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2195.34, "gross_charge": 3377.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166571", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0677-46", "type": "NDC" } ], "description": "PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 57 GR", "billing_class": "facility", "discounted_cash": 10.43, "gross_charge": 16.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166611", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "49702-0228-13", "type": "NDC" } ], "description": "DOLUTEGRAVIR 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 156.06, "gross_charge": 240.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166882", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64764-0730-30", "type": "NDC" } ], "description": "VORTIOXETINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 35.2, "gross_charge": 54.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166883", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64764-0750-30", "type": "NDC" } ], "description": "VORTIOXETINE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 35.2, "gross_charge": 54.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166909", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50419-0250-01", "type": "NDC" } ], "description": "RIOCIGUAT 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 322.98, "gross_charge": 496.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166910", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50419-0251-01", "type": "NDC" } ], "description": "RIOCIGUAT 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 322.98, "gross_charge": 496.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166913", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50419-0254-91", "type": "NDC" } ], "description": "RIOCIGUAT 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 282.23, "gross_charge": 434.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-166988", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "66215-0501-15", "type": "NDC" } ], "description": "MACITENTAN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 815.72, "gross_charge": 1254.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167037", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9301", "type": "HCPCS" }, { "code": "50242-0070-01", "type": "NDC" } ], "description": "OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 40 ML", "billing_class": "facility", "discounted_cash": 24320.5, "gross_charge": 37416.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167070", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1143-98", "type": "NDC" } ], "description": "WHITE PETROLATUM 42 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 454 GR", "billing_class": "facility", "discounted_cash": 5.04, "gross_charge": 7.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167100", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1186-12", "type": "NDC" } ], "description": "PHENYLEPHRINE 0.25 %-COCOA BUTTER 88.44 % RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167157", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0523-11", "type": "NDC" } ], "description": "POSACONAZOLE 100 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 41.96, "gross_charge": 64.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167178", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "60635-0118-01", "type": "NDC" } ], "description": "POLIDOCANOL 1 % INTRAVENOUS FOAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 1184.36, "gross_charge": 1822.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167214", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00480-7062-56", "type": "NDC" } ], "description": "PERAMPANEL 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 47.94, "gross_charge": 73.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167216", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69616-0276-30", "type": "NDC" } ], "description": "PERAMPANEL 6 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 107.84, "gross_charge": 165.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167236", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "66302-0310-02", "type": "NDC" } ], "description": "TREPROSTINIL DIOLAMINE ER 1 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 132.7, "gross_charge": 204.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167286", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00173-0869-10", "type": "NDC" } ], "description": "UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.3, "gross_charge": 28.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167304", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "66993-0456-30", "type": "NDC" } ], "description": "DAPAGLIFLOZIN PROPANEDIOL 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 26.68, "gross_charge": 41.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167305", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00310-6210-39", "type": "NDC" } ], "description": "DAPAGLIFLOZIN PROPANEDIOL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 33.8, "gross_charge": 52.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167359", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1595", "type": "HCPCS" }, { "code": "00781-3250-89", "type": "NDC" } ], "description": "GLATIRAMER 40 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 349.21, "gross_charge": 537.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167443", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0290-06", "type": "NDC" } ], "description": "ESLICARBAZEPINE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.37, "gross_charge": 9.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167445", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0291-06", "type": "NDC" } ], "description": "ESLICARBAZEPINE 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.92, "gross_charge": 10.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167524", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "00409-1891-01", "type": "NDC" } ], "description": "MORPHINE 4 MG/ML INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 26.36, "gross_charge": 40.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167557", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "68462-0911-01", "type": "NDC" } ], "description": "POSACONAZOLE 300 MG/16.7 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16.7 ML", "billing_class": "facility", "discounted_cash": 268.32, "gross_charge": 412.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-167769", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9308", "type": "HCPCS" }, { "code": "00002-7669-01", "type": "NDC" } ], "description": "RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 4099.91, "gross_charge": 6307.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-16830", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "20555-0036-01", "type": "NDC" } ], "description": "MELATONIN 3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-169090", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8530", "type": "HCPCS" }, { "code": "43975-0308-10", "type": "NDC" } ], "description": "CYCLOPHOSPHAMIDE 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 29.9, "gross_charge": 46.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-169092", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0572-01", "type": "NDC" } ], "description": "GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.46, "gross_charge": 0.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-169186", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7168", "type": "HCPCS" }, { "code": "63833-0386-02", "type": "NDC" } ], "description": "HUMAN PROTHROMBIN COMPLEX,4-FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2412.6, "gross_charge": 3711.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-169212", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3380", "type": "HCPCS" }, { "code": "64764-0300-20", "type": "NDC" } ], "description": "VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 30377.88, "gross_charge": 46735.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-169346", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7168", "type": "HCPCS" }, { "code": "63833-0387-02", "type": "NDC" } ], "description": "HUM PROTHROMBIN CPLX, 4-FACTOR 1,000 UNIT (800-1,240 UNIT) IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4771.81, "gross_charge": 7341.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-169803", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9032", "type": "HCPCS" }, { "code": "72893-0002-01", "type": "NDC" } ], "description": "BELINOSTAT 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6875.67, "gross_charge": 10577.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-169891", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "42367-0540-32", "type": "NDC" } ], "description": "DANTROLENE 250 MG INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6736.02, "gross_charge": 10363.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170138", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "72205-0072-90", "type": "NDC" } ], "description": "DROXIDOPA 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.1, "gross_charge": 7.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170209", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00597-0153-30", "type": "NDC" } ], "description": "EMPAGLIFLOZIN 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34.32, "gross_charge": 52.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170210", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00597-0152-30", "type": "NDC" } ], "description": "EMPAGLIFLOZIN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34.32, "gross_charge": 52.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17023", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42192-0339-01", "type": "NDC" } ], "description": "HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170545", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1595", "type": "HCPCS" }, { "code": "68546-0317-30", "type": "NDC" } ], "description": "GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 773.01, "gross_charge": 1189.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170551", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42858-0353-40", "type": "NDC" } ], "description": "BUPRENORPHINE 7.5 MCG/HOUR WEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 103.32, "gross_charge": 158.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170552", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00327-0001-10", "type": "NDC" } ], "description": "OXYCHLOROSENE SODIUM TOPICAL POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 GR", "billing_class": "facility", "discounted_cash": 13.78, "gross_charge": 21.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170575", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2407", "type": "HCPCS" }, { "code": "70842-0140-03", "type": "NDC" } ], "description": "ORITAVANCIN 400 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3513.35, "gross_charge": 5405.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170653", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-2895-20", "type": "NDC" } ], "description": "FERRIC CITRATE 210 MG IRON TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.6, "gross_charge": 24.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170715", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00002-1433-80", "type": "NDC" } ], "description": "DULAGLUTIDE 0.75 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 466.47, "gross_charge": 717.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170716", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00002-1434-80", "type": "NDC" } ], "description": "DULAGLUTIDE 1.5 MG/0.5 ML SUBCUTANEOUS PEN INJECTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 929.96, "gross_charge": 1430.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170958", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3535", "type": "HCPCS" }, { "code": "00597-0100-51", "type": "NDC" } ], "description": "TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION MIST FOR INHALATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 GR", "billing_class": "facility", "discounted_cash": 93.34, "gross_charge": 143.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-170978", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61958-1401-01", "type": "NDC" } ], "description": "COBICISTAT 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 22.72, "gross_charge": 34.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171003", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0358-25", "type": "NDC" } ], "description": "COLCHICINE 0.6 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.38, "gross_charge": 17.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171117", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1561", "type": "HCPCS" }, { "code": "13533-0800-41", "type": "NDC" } ], "description": "IMMUNE GLOB G 40 GRAM/400 ML(10%)-GLY-IGA AVE 46 MCG/ML INJECTION SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 400 ML", "billing_class": "facility", "discounted_cash": 7372.04, "gross_charge": 11341.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17121", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9201", "type": "HCPCS" }, { "code": "00409-0185-01", "type": "NDC" } ], "description": "GEMCITABINE 200 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 80.24, "gross_charge": 123.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171371", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2598", "type": "HCPCS" }, { "code": "55150-0370-24", "type": "NDC" } ], "description": "VASOPRESSIN 20 UNIT/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 29.74, "gross_charge": 45.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171407", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0202", "type": "HCPCS" }, { "code": "58468-0200-01", "type": "NDC" } ], "description": "ALEMTUZUMAB 12 MG/1.2 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.2 ML", "billing_class": "facility", "discounted_cash": 75627.53, "gross_charge": 116350.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171532", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2547", "type": "HCPCS" }, { "code": "61364-0181-01", "type": "NDC" } ], "description": "PERAMIVIR (PF) 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 1019.46, "gross_charge": 1568.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171549", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00173-0874-14", "type": "NDC" } ], "description": "FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 179.69, "gross_charge": 276.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171615", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9039", "type": "HCPCS" }, { "code": "55513-0160-01", "type": "NDC" } ], "description": "BLINATUMOMAB 35 MCG INTRAVENOUS KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15035.9, "gross_charge": 23132.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171680", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0695", "type": "HCPCS" }, { "code": "67919-0030-01", "type": "NDC" } ], "description": "CEFTOLOZANE-TAZOBACTAM 1.5 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 546.94, "gross_charge": 841.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171700", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9299", "type": "HCPCS" }, { "code": "00003-3772-11", "type": "NDC" } ], "description": "NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 3622.81, "gross_charge": 5573.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171701", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9299", "type": "HCPCS" }, { "code": "00003-3774-12", "type": "NDC" } ], "description": "NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 8976.92, "gross_charge": 13810.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171927", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90620", "type": "HCPCS" }, { "code": "58160-0976-20", "type": "NDC" } ], "description": "MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 700.73, "gross_charge": 1078.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171929", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59011-0410-20", "type": "NDC" } ], "description": "OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.29, "gross_charge": 26.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171930", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59011-0415-20", "type": "NDC" } ], "description": "OXYCODONE ER 15 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 22.94, "gross_charge": 35.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171931", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59011-0420-20", "type": "NDC" } ], "description": "OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27.62, "gross_charge": 42.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-171933", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59011-0440-20", "type": "NDC" } ], "description": "OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 43.45, "gross_charge": 66.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172035", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "64896-0661-01", "type": "NDC" } ], "description": "CARBIDOPA ER 23.75 MG-LEVODOPA 95 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.82, "gross_charge": 16.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172036", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "64896-0662-01", "type": "NDC" } ], "description": "CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.82, "gross_charge": 16.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172037", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "64896-0663-01", "type": "NDC" } ], "description": "CARBIDOPA ER 48.75 MG-LEVODOPA 195 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.82, "gross_charge": 16.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172038", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "64896-0664-01", "type": "NDC" } ], "description": "CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.8, "gross_charge": 19.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172050", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2506", "type": "HCPCS" }, { "code": "55513-0192-01", "type": "NDC" } ], "description": "PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 10005.45, "gross_charge": 15393.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172073", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "82625-8801-01", "type": "NDC" } ], "description": "NALOXEGOL 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 30.32, "gross_charge": 46.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172074", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "82625-8802-01", "type": "NDC" } ], "description": "NALOXEGOL 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 30.32, "gross_charge": 46.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172084", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9271", "type": "HCPCS" }, { "code": "00006-3026-02", "type": "NDC" } ], "description": "PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 16273.24, "gross_charge": 25035.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172605", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "38396-0913-63", "type": "NDC" } ], "description": "DEXTROSE 15 GRAM/33 GRAM ORAL GEL PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 33 GR", "billing_class": "facility", "discounted_cash": 10.01, "gross_charge": 15.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172616", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00469-0520-02", "type": "NDC" } ], "description": "ISAVUCONAZONIUM SULFATE 186 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 220.32, "gross_charge": 338.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17280", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0055-01", "type": "NDC" } ], "description": "SELEGILINE 5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.93, "gross_charge": 6.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17285", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9351", "type": "HCPCS" }, { "code": "63323-0762-10", "type": "NDC" } ], "description": "TOPOTECAN 4 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 125.12, "gross_charge": 192.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172896", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0362-60", "type": "NDC" } ], "description": "IVABRADINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.42, "gross_charge": 6.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172899", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2353", "type": "HCPCS" }, { "code": "00078-0818-81", "type": "NDC" } ], "description": "OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14506.6, "gross_charge": 22317.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172900", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2353", "type": "HCPCS" }, { "code": "00078-0825-81", "type": "NDC" } ], "description": "OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21711.85, "gross_charge": 33402.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172901", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2353", "type": "HCPCS" }, { "code": "00078-0811-81", "type": "NDC" } ], "description": "OCTREOTIDE,MICROSPHERES ER 10 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11077.36, "gross_charge": 17042.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172906", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00173-0882-10", "type": "NDC" } ], "description": "FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.76, "gross_charge": 24.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172920", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0714", "type": "HCPCS" }, { "code": "00456-2700-10", "type": "NDC" } ], "description": "CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1210.82, "gross_charge": 1862.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172923", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1569", "type": "HCPCS" }, { "code": "00944-2700-04", "type": "NDC" } ], "description": "IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 1001.23, "gross_charge": 1540.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172924", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1459", "type": "HCPCS" }, { "code": "44206-0437-10", "type": "NDC" } ], "description": "IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 1979.51, "gross_charge": 3045.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172924", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1459", "type": "HCPCS" }, { "code": "44206-0438-20", "type": "NDC" } ], "description": "IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 3920.83, "gross_charge": 6032.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172924", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1459", "type": "HCPCS" }, { "code": "44206-0439-40", "type": "NDC" } ], "description": "IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 400 ML", "billing_class": "facility", "discounted_cash": 7803.44, "gross_charge": 12005.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172924", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1459", "type": "HCPCS" }, { "code": "44206-0436-05", "type": "NDC" } ], "description": "IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 1008.86, "gross_charge": 1552.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-172950", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7297", "type": "HCPCS" }, { "code": "00023-5858-01", "type": "NDC" } ], "description": "LEVONORGESTREL 20.4 MCG/24 HR (UP TO 8 YRS) 52 MG INTRAUTERINE DEVICE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1160.93, "gross_charge": 1786.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173114", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1611", "type": "HCPCS" }, { "code": "63323-0594-03", "type": "NDC" } ], "description": "GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 393.28, "gross_charge": 605.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173168", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "00000-0105-22", "type": "NDC" } ], "description": "CEFAZOLIN 3 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 46.25, "gross_charge": 71.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17378", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0740", "type": "HCPCS" }, { "code": "23155-0216-31", "type": "NDC" } ], "description": "CIDOFOVIR 75 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 1528.54, "gross_charge": 2351.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17379", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2185", "type": "HCPCS" }, { "code": "63323-0507-21", "type": "NDC" } ], "description": "MEROPENEM 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 29.09, "gross_charge": 44.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17380", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2185", "type": "HCPCS" }, { "code": "63323-0508-31", "type": "NDC" } ], "description": "MEROPENEM 1 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34.97, "gross_charge": 53.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173832", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1566", "type": "HCPCS" }, { "code": "00944-2658-04", "type": "NDC" } ], "description": "IMMUNE GLOB,GAMMA(IGG) 10 GRAM-GLY-GLUC-IGA 0 TO 50 MCG/ML IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4194.22, "gross_charge": 6452.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173855", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9460", "type": "HCPCS" }, { "code": "10122-0620-10", "type": "NDC" } ], "description": "CANGRELOR 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3033.22, "gross_charge": 4666.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17387", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50111-0789-10", "type": "NDC" } ], "description": "AZITHROMYCIN 600 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.4, "gross_charge": 9.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173925", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00078-0659-20", "type": "NDC" } ], "description": "SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.09, "gross_charge": 38.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173926", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00078-0777-67", "type": "NDC" } ], "description": "SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.09, "gross_charge": 38.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173927", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00078-0696-67", "type": "NDC" } ], "description": "SACUBITRIL 97 MG-VALSARTAN 103 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.09, "gross_charge": 38.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173951", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59148-0036-13", "type": "NDC" } ], "description": "BREXPIPRAZOLE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 97.89, "gross_charge": 150.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173952", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59148-0037-13", "type": "NDC" } ], "description": "BREXPIPRAZOLE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 97.89, "gross_charge": 150.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-173953", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59148-0038-13", "type": "NDC" } ], "description": "BREXPIPRAZOLE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 97.89, "gross_charge": 150.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1740", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0243-01", "type": "NDC" } ], "description": "CLINDAMYCIN HCL 150 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17403", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-4050-91", "type": "NDC" } ], "description": "NEVIRAPINE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17405", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" }, { "code": "00024-5926-05", "type": "NDC" } ], "description": "INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 58.73, "gross_charge": 90.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1742", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0562-02", "type": "NDC" } ], "description": "CLINDAMYCIN PHOSPHATE 1 % TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 27.82, "gross_charge": 42.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17451", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9181", "type": "HCPCS" }, { "code": "61269-0410-20", "type": "NDC" } ], "description": "ETOPOSIDE PHOSPHATE 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 480.22, "gross_charge": 738.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17465", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0120-01", "type": "NDC" } ], "description": "MIRTAZAPINE 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17466", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0119-01", "type": "NDC" } ], "description": "MIRTAZAPINE 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-174718", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5101", "type": "HCPCS" }, { "code": "61314-0326-01", "type": "NDC" } ], "description": "FILGRASTIM-SNDZ 480 MCG/0.8 ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 891.02, "gross_charge": 1370.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-174719", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5101", "type": "HCPCS" }, { "code": "61314-0318-01", "type": "NDC" } ], "description": "FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 891.02, "gross_charge": 1370.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-174797", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00186-0776-60", "type": "NDC" } ], "description": "TICAGRELOR 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.48, "gross_charge": 26.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175177", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9352", "type": "HCPCS" }, { "code": "59676-0610-01", "type": "NDC" } ], "description": "TRABECTEDIN 1 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10000.8, "gross_charge": 15385.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175182", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2184", "type": "HCPCS" }, { "code": "00264-3183-11", "type": "NDC" } ], "description": "MEROPENEM 500 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 67.11, "gross_charge": 103.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175183", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2184", "type": "HCPCS" }, { "code": "00264-3185-11", "type": "NDC" } ], "description": "MEROPENEM 1 GRAM/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 77.28, "gross_charge": 118.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175186", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8670", "type": "HCPCS" }, { "code": "70720-0101-02", "type": "NDC" } ], "description": "ROLAPITANT 90 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 672.62, "gross_charge": 1034.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175213", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "00641-6125-25", "type": "NDC" } ], "description": "MORPHINE 4 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 28.54, "gross_charge": 43.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175244", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1944", "type": "HCPCS" }, { "code": "65757-0402-03", "type": "NDC" } ], "description": "ARIPIPRAZOLE LAUROXIL ER 662 MG/2.4 ML SUSPENSION, EXT.REL. IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.4 ML", "billing_class": "facility", "discounted_cash": 7220.4, "gross_charge": 11108.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175245", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1944", "type": "HCPCS" }, { "code": "65757-0401-03", "type": "NDC" } ], "description": "ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.6 ML", "billing_class": "facility", "discounted_cash": 4817.08, "gross_charge": 7410.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175246", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1944", "type": "HCPCS" }, { "code": "65757-0403-03", "type": "NDC" } ], "description": "ARIPIPRAZOLE LAUROXIL ER 882 MG/3.2 ML SUSPENSION, EXT.REL. IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.2 ML", "billing_class": "facility", "discounted_cash": 9612.72, "gross_charge": 14788.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175296", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0321-25", "type": "NDC" } ], "description": "PHENYLEPHRINE 50 MG/250 ML (200 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 98.12, "gross_charge": 150.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175313", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2251", "type": "HCPCS" }, { "code": "00143-9380-01", "type": "NDC" } ], "description": "MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 70.62, "gross_charge": 108.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175328", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00597-0197-05", "type": "NDC" } ], "description": "IDARUCIZUMAB 2.5 GRAM/50 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 8254.16, "gross_charge": 12698.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175346", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9205", "type": "HCPCS" }, { "code": "15054-0043-01", "type": "NDC" } ], "description": "IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 8285.03, "gross_charge": 12746.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175367", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9325", "type": "HCPCS" }, { "code": "55513-0078-01", "type": "NDC" } ], "description": "TALIMOGENE LAHERPAREPVEC 10EXP6 (1 MILLION) PFU/ML SUSP FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 243.65, "gross_charge": 374.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175368", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9325", "type": "HCPCS" }, { "code": "55513-0079-01", "type": "NDC" } ], "description": "TALIMOGENE LAHERPAREPVEC 10EXP8 (100 MILLION)PFU/ML SUSP FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 19079.16, "gross_charge": 29352.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175379", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "86790-0162-80", "type": "NDC" } ], "description": "WHEAT DEXTRIN 3 GRAM/4 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.26, "gross_charge": 0.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1754", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0818-95", "type": "NDC" } ], "description": "CLOMIPRAMINE 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.08, "gross_charge": 35.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175407", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61958-1901-01", "type": "NDC" } ], "description": "ELVITEG 150 MG-COB 150 MG-EMTRICIT 200 MG-TENOFO ALAFENAM 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 280.51, "gross_charge": 431.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175414", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0689", "type": "HCPCS" }, { "code": "00338-3508-41", "type": "NDC" } ], "description": "CEFAZOLIN 2 GRAM/100 ML IN DEXTROSE(ISO-OSMOTIC) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 63.54, "gross_charge": 97.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175422", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-0303-16", "type": "NDC" } ], "description": "COMPOUNDING VEHICLE SUSPENSION SUGAR-FREE NO.20 ORAL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 10.46, "gross_charge": 16.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1755", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0113-01", "type": "NDC" } ], "description": "CLONIDINE HCL 0.1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1756", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0124-01", "type": "NDC" } ], "description": "CLONIDINE HCL 0.2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175759", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0571", "type": "HCPCS" }, { "code": "59385-0021-60", "type": "NDC" } ], "description": "BUPRENORPHINE HCL 75 MCG BUCCAL FILM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.21, "gross_charge": 37.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175760", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0571", "type": "HCPCS" }, { "code": "59385-0022-60", "type": "NDC" } ], "description": "BUPRENORPHINE HCL 150 MCG BUCCAL FILM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.21, "gross_charge": 37.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175761", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0571", "type": "HCPCS" }, { "code": "59385-0023-01", "type": "NDC" } ], "description": "BUPRENORPHINE HCL 300 MCG BUCCAL FILM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34.97, "gross_charge": 53.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175776", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "53436-0084-01", "type": "NDC" } ], "description": "PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 63.12, "gross_charge": 97.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175871", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9176", "type": "HCPCS" }, { "code": "00003-2291-11", "type": "NDC" } ], "description": "ELOTUZUMAB 300 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6311.86, "gross_charge": 9710.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-175872", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9176", "type": "HCPCS" }, { "code": "00003-4522-11", "type": "NDC" } ], "description": "ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8397.94, "gross_charge": 12919.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176034", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9034", "type": "HCPCS" }, { "code": "63459-0348-04", "type": "NDC" } ], "description": "BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 3834.02, "gross_charge": 5898.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176089", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "66215-0602-06", "type": "NDC" } ], "description": "SELEXIPAG 200 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 536.77, "gross_charge": 825.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176250", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00006-5423-12", "type": "NDC" } ], "description": "SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 431.76, "gross_charge": 664.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176263", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "45802-0040-64", "type": "NDC" } ], "description": "SELENIUM SULFIDE 2.5 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 120 ML", "billing_class": "facility", "discounted_cash": 27.82, "gross_charge": 42.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176319", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "24571-0116-06", "type": "NDC" } ], "description": "PHOSPHATE DIALYSIS SOLN WITHOUT DEXTR K 4 MEQ-CA 2.5 MEQ-PO4 1 MMOL/L", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 187.98, "gross_charge": 289.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176887", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00000-0003-75", "type": "NDC" } ], "description": "FENTANYL (PF) 300 MCG/30 ML (10 MCG/ML) IN 0.9 % NACL IV PCA SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176888", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00000-0003-75", "type": "NDC" } ], "description": "FENTANYL (PF) 300 MCG/30 ML (10 MCG/ML) IN 0.9 % NACL IV PCA SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176890", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "71286-2011-01", "type": "NDC" } ], "description": "HYDROMORPHONE 0.5 MG/ML PCA HIGH RISK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 65.32, "gross_charge": 100.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176891", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "71286-2011-01", "type": "NDC" } ], "description": "HYDROMORPHONE 0.5 MG/ML PCA HIGH RISK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 65.32, "gross_charge": 100.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1769", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-2003-06", "type": "NDC" } ], "description": "CLOTRIMAZOLE 1 % VAGINAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 45 GR", "billing_class": "facility", "discounted_cash": 15.76, "gross_charge": 24.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176904", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61874-0115-20", "type": "NDC" } ], "description": "CARIPRAZINE 1.5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 98.05, "gross_charge": 150.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-176905", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61874-0130-20", "type": "NDC" } ], "description": "CARIPRAZINE 3 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 98.05, "gross_charge": 150.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177052", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "71285-0202-01", "type": "NDC" } ], "description": "CARDIOPLEGIC SOLUTION NO.16 26 MEQ/1,052.8 ML(POTASSIUM) FOR PERFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1052.8 ML", "billing_class": "facility", "discounted_cash": 225.48, "gross_charge": 346.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177101", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "61958-2101-01", "type": "NDC" } ], "description": "EMTRICITABINE 200 MG-RILPIVIRINE 25 MG-TENOFOVIR ALAFENAM 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 255.55, "gross_charge": 393.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177620", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "71286-2011-01", "type": "NDC" } ], "description": "HYDROMORPHONE 0.5 MG/ML PCA HIGH RISK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 65.32, "gross_charge": 100.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177623", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00000-0003-75", "type": "NDC" } ], "description": "FENTANYL (PF) 300 MCG/30 ML (10 MCG/ML) IN 0.9 % NACL IV PCA SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177631", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "j3490", "type": "HCPCS" }, { "code": "68727-0800-02", "type": "NDC" } ], "description": "DEFIBROTIDE 80 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 2695.13, "gross_charge": 4146.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177708", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q2004", "type": "HCPCS" }, { "code": "00327-0012-30", "type": "NDC" } ], "description": "CITRIC AC 1980.6 MG-GLUCONO 59.4 MG-MAG CARB 980.4 MG/30 ML IRRIG.SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 53.4, "gross_charge": 82.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177732", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00000-0102-38", "type": "NDC" } ], "description": "VANCOMYCIN 1.5 GRAM/500 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 61.36, "gross_charge": 94.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177760", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00074-0561-11", "type": "NDC" } ], "description": "VENETOCLAX 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 29.28, "gross_charge": 45.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177761", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00074-0566-11", "type": "NDC" } ], "description": "VENETOCLAX 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 134.52, "gross_charge": 206.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-177762", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00074-0576-30", "type": "NDC" } ], "description": "VENETOCLAX 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 266.01, "gross_charge": 409.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17801", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "52817-0816-15", "type": "NDC" } ], "description": "ACETIC ACID 2 % EAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 58.44, "gross_charge": 89.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178105", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "50474-0970-75", "type": "NDC" } ], "description": "BRIVARACETAM 50 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 29.02, "gross_charge": 44.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178108", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "50474-0470-66", "type": "NDC" } ], "description": "BRIVARACETAM 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178109", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "50474-0570-09", "type": "NDC" } ], "description": "BRIVARACETAM 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178174", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24510-0110-10", "type": "NDC" } ], "description": "OXYCODONE ER 9 MG CAPSULE SPRINKLE EXTENDED RELEASE 12 HR(DON'T CRUSH)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.47, "gross_charge": 23.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178175", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24510-0115-10", "type": "NDC" } ], "description": "OXYCODONE ER 13.5 MG CAPSULE SPRINKLE EXTEND RELEASE 12HR(DON'T CRUSH)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21.32, "gross_charge": 32.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178178", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24510-0140-10", "type": "NDC" } ], "description": "OXYCODONE ER 36 MG CAPSULE SPRINKLE EXTENDED RELEASE 12HR(DON'T CRUSH)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 42.8, "gross_charge": 65.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178217", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "43598-0725-25", "type": "NDC" } ], "description": "EPHEDRINE SULFATE 50 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 22.68, "gross_charge": 34.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178229", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9022", "type": "HCPCS" }, { "code": "50242-0917-01", "type": "NDC" } ], "description": "ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 31301.37, "gross_charge": 48155.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178243", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00338-3582-01", "type": "NDC" } ], "description": "VANCOMYCIN 750 MG/150 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 150 ML", "billing_class": "facility", "discounted_cash": 73.35, "gross_charge": 112.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178276", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0556-33", "type": "NDC" } ], "description": "MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.9, "gross_charge": 19.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17837", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3535", "type": "HCPCS" }, { "code": "00781-7296-85", "type": "NDC" } ], "description": "ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6.7 GR", "billing_class": "facility", "discounted_cash": 46.18, "gross_charge": 71.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178449", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00000-0104-38", "type": "NDC" } ], "description": "FENTANYL PCA (PALLIATIVE CARE) 2500 MCG/50 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 50.99, "gross_charge": 78.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-178450", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "00000-0104-39", "type": "NDC" } ], "description": "HYDROMORPHONE PCA (PALLIATIVE CARE) 500 MG/50 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 332.67, "gross_charge": 511.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17881", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70069-0231-01", "type": "NDC" } ], "description": "BRIMONIDINE 0.2 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 12.68, "gross_charge": 19.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-179011", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0820-04", "type": "NDC" } ], "description": "FAT EMULSION-SOYBEAN OIL-MCT-OLIVE OIL-FISH OIL 20 % INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 102.47, "gross_charge": 157.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-179041", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46287-0006-60", "type": "NDC" } ], "description": "SODIUM POLYSTYRENE SULFONATE 15 GRAM-SORBITOL 20 GRAM/60 ML ORAL SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 66.07, "gross_charge": 101.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-179327", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00517-0374-05", "type": "NDC" } ], "description": "METHYLENE BLUE (ANTIDOTE) 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 286.65, "gross_charge": 441.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17936", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3111-00", "type": "NDC" } ], "description": "OLANZAPINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-179452", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3358", "type": "HCPCS" }, { "code": "57894-0054-27", "type": "NDC" } ], "description": "USTEKINUMAB 130 MG/26 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 26 ML", "billing_class": "facility", "discounted_cash": 6892.54, "gross_charge": 10603.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-179600", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5103", "type": "HCPCS" }, { "code": "00069-0809-01", "type": "NDC" } ], "description": "INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1869.27, "gross_charge": 2875.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17961", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0024-60", "type": "NDC" } ], "description": "ZIDOVUDINE 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-179621", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7296", "type": "HCPCS" }, { "code": "50419-0424-01", "type": "NDC" } ], "description": "LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2211.85, "gross_charge": 3402.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-179627", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "00000-0015-32", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 100 MG/20 ML (5 MG/ML) 0.5 % INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 272.09, "gross_charge": 418.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-17997", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "63044-0404-20", "type": "NDC" } ], "description": "AMMONIUM LACTATE 12 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 140 GR", "billing_class": "facility", "discounted_cash": 22.0, "gross_charge": 33.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1801", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-0243-24", "type": "NDC" } ], "description": "CODEINE SULFATE 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.15, "gross_charge": 11.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-180111", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0565", "type": "HCPCS" }, { "code": "00006-3025-00", "type": "NDC" } ], "description": "BEZLOTOXUMAB 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 40 ML", "billing_class": "facility", "discounted_cash": 10299.15, "gross_charge": 15844.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-1802", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-0244-25", "type": "NDC" } ], "description": "CODEINE SULFATE 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.28, "gross_charge": 11.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-180473", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "48582-0512-01", "type": "NDC" } ], "description": "SALIVA STIMULANT COMBINATION NO.7 ORAL MUCOSAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 42 GR", "billing_class": "facility", "discounted_cash": 22.42, "gross_charge": 34.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-180484", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65649-0003-30", "type": "NDC" } ], "description": "PLECANATIDE 3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 38.42, "gross_charge": 59.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-180504", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "76045-0009-96", "type": "NDC" } ], "description": "HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 30.16, "gross_charge": 46.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-180885", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9023", "type": "HCPCS" }, { "code": "44087-3535-01", "type": "NDC" } ], "description": "AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 5699.4, "gross_charge": 8768.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-180899", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2350", "type": "HCPCS" }, { "code": "50242-0150-01", "type": "NDC" } ], "description": "OCRELIZUMAB 30 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 55706.88, "gross_charge": 85702.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-181274", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9340", "type": "HCPCS" }, { "code": "65219-0029-20", "type": "NDC" } ], "description": "THIOTEPA 100 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4814.55, "gross_charge": 7407.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-181278", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50242-0122-06", "type": "NDC" } ], "description": "PIRFENIDONE 267 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 81.22, "gross_charge": 124.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-181723", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9355", "type": "HCPCS" }, { "code": "50242-0132-01", "type": "NDC" } ], "description": "TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4256.17, "gross_charge": 6547.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-181755", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0737", "type": "HCPCS" }, { "code": "00338-9549-24", "type": "NDC" } ], "description": "CLINDAMYCIN 600 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 51.54, "gross_charge": 79.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-181756", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0737", "type": "HCPCS" }, { "code": "00338-9553-24", "type": "NDC" } ], "description": "CLINDAMYCIN 900 MG/50 ML IN 0.9% SODIUM CHLORIDE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 54.66, "gross_charge": 84.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-181765", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00078-0698-02", "type": "NDC" } ], "description": "MIDOSTAURIN 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 433.32, "gross_charge": 666.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-181771", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9173", "type": "HCPCS" }, { "code": "00310-4500-12", "type": "NDC" } ], "description": "DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.4 ML", "billing_class": "facility", "discounted_cash": 2832.47, "gross_charge": 4357.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18192", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "25021-0671-67", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 116.09, "gross_charge": 178.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18194", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "63323-0288-03", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 38.94, "gross_charge": 59.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18195", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "63323-0286-35", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 28.92, "gross_charge": 44.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182001", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9311", "type": "HCPCS" }, { "code": "50242-0108-01", "type": "NDC" } ], "description": "RITUXIMAB 1,400 MG/11.7 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 11.7 ML", "billing_class": "facility", "discounted_cash": 17785.56, "gross_charge": 27362.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182023", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62530-0000-11", "type": "NDC" } ], "description": "UREA 15 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.15, "gross_charge": 17.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182032", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1944", "type": "HCPCS" }, { "code": "65757-0404-03", "type": "NDC" } ], "description": "ARIPIPRAZOLE LAUROXIL ER 1,064 MG/3.9 ML SUSPENSION,EXT.REL IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.9 ML", "billing_class": "facility", "discounted_cash": 11591.94, "gross_charge": 17833.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182080", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9311", "type": "HCPCS" }, { "code": "50242-0109-01", "type": "NDC" } ], "description": "RITUXIMAB 1,600 MG/13.4 ML (120 MG/ML)-HYALURONIDASE SUBCUTANEOUS SOLN|DISCARDED DRUG NOT ADMINISTERED", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 11.725 ML", "billing_class": "facility", "discounted_cash": 17898.95, "gross_charge": 27536.85, "setting": "both" }, { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 11.725 ML | The modified price is presented in the standard charge value. | Modifier JW: Drug amount discarded/not administered to any patient", "billing_class": "facility", "discounted_cash": 17898.95, "gross_charge": 27536.85, "modifiers": "JW", "setting": "both" } ] }, { "code_information": [ { "code": "RX-1821", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0187-15", "type": "NDC" } ], "description": "COLCHICINE 0.6 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.9, "gross_charge": 12.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182532", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5104", "type": "HCPCS" }, { "code": "78206-0162-01", "type": "NDC" } ], "description": "INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1035.22, "gross_charge": 1592.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18260", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-28", "type": "NDC" } ], "description": "TRACE ELEMENTS CR-CU-MN-SE-ZN 4-400-100-20 MCG-1000 MCG/ML IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 145.14, "gross_charge": 223.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18262", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00517-7201-25", "type": "NDC" } ], "description": "TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 36.08, "gross_charge": 55.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182724", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69238-2027-08", "type": "NDC" } ], "description": "SPIRONOLACTONE 25 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 38.51, "gross_charge": 59.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182810", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9153", "type": "HCPCS" }, { "code": "68727-0745-02", "type": "NDC" } ], "description": "DAUNORUBICIN 44 MG AND CYTARABINE 100 MG IN LIPOSOME IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 29658.33, "gross_charge": 45628.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182823", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9229", "type": "HCPCS" }, { "code": "00008-0100-01", "type": "NDC" } ], "description": "INOTUZUMAB OZOGAMICIN 0.9 MG(0.25 MG/ML INITIAL CONCENTRATION) IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 64537.1, "gross_charge": 99287.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18288", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0679-11", "type": "NDC" } ], "description": "BISOPROLOL FUMARATE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18293", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0539-01", "type": "NDC" } ], "description": "TORSEMIDE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18295", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0754-15", "type": "NDC" } ], "description": "TORSEMIDE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182971", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2042", "type": "HCPCS" }, { "code": "00078-0846-19", "type": "NDC" } ], "description": "TISAGENLECLEUCEL 0.2 X10EXP6 TO 2.5X10EXP8 CELL INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1616541.39, "gross_charge": 2486986.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-182980", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9203", "type": "HCPCS" }, { "code": "00008-4510-01", "type": "NDC" } ], "description": "GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONCENTRATION) IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27543.62, "gross_charge": 42374.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18302", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2543", "type": "HCPCS" }, { "code": "70860-0122-41", "type": "NDC" } ], "description": "PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 38.38, "gross_charge": 59.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183036", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "71286-2011-01", "type": "NDC" } ], "description": "HYDROMORPHONE 0.5 MG/ML PCA HIGH RISK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 65.32, "gross_charge": 100.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18307", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0602-01", "type": "NDC" } ], "description": "GABAPENTIN 400 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18308", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0591-01", "type": "NDC" } ], "description": "GABAPENTIN 300 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18309", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0580-01", "type": "NDC" } ], "description": "GABAPENTIN 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18311", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0273-01", "type": "NDC" } ], "description": "RISPERIDONE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18312", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0274-11", "type": "NDC" } ], "description": "RISPERIDONE 3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18313", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0272-01", "type": "NDC" } ], "description": "RISPERIDONE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18315", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1250", "type": "HCPCS" }, { "code": "00338-1075-02", "type": "NDC" } ], "description": "DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 68.15, "gross_charge": 104.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183156", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2186", "type": "HCPCS" }, { "code": "70842-0120-06", "type": "NDC" } ], "description": "MEROPENEM-VABORBACTAM 2 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 740.32, "gross_charge": 1138.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183196", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00173-0887-10", "type": "NDC" } ], "description": "FLUTICASONE FUR. 100 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.21, "gross_charge": 37.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183265", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2041", "type": "HCPCS" }, { "code": "71287-0119-01", "type": "NDC" } ], "description": "AXICABTAGENE CILOLEUCEL INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1258310.33, "gross_charge": 1935862.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183277", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90750", "type": "HCPCS" }, { "code": "58160-0819-12", "type": "NDC" } ], "description": "VARICELLA-ZOSTER GLYCOE VACC-AS01B ADJ(PF) 50 MCG/0.5 ML IM SUSP, KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 530.86, "gross_charge": 816.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183279", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90750", "type": "HCPCS" }, { "code": "58160-0828-03", "type": "NDC" } ], "description": "VARICELLA-ZOSTER GLYCOP E VACCINE (VIAL 2 OF 2) 50 MCG IM SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 670.34, "gross_charge": 1031.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183543", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00006-3076-01", "type": "NDC" } ], "description": "LETERMOVIR 480 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 563.03, "gross_charge": 866.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-183545", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00006-5004-01", "type": "NDC" } ], "description": "LETERMOVIR 480 MG/24 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 24 ML", "billing_class": "facility", "discounted_cash": 1264.44, "gross_charge": 1945.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18385", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0697-01", "type": "NDC" } ], "description": "BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.22, "gross_charge": 6.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18386", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0708-25", "type": "NDC" } ], "description": "BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.06, "gross_charge": 6.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18398", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "72078-0034-01", "type": "NDC" } ], "description": "REMIFENTANIL 1 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 94.64, "gross_charge": 145.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184017", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9048", "type": "HCPCS" }, { "code": "63323-0721-10", "type": "NDC" } ], "description": "BORTEZOMIB 3.5 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3409.41, "gross_charge": 5245.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184031", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9299", "type": "HCPCS" }, { "code": "00003-3734-13", "type": "NDC" } ], "description": "NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 24 ML", "billing_class": "facility", "discounted_cash": 21469.99, "gross_charge": 33030.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184305", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61958-2501-01", "type": "NDC" } ], "description": "BICTEGRAVIR 50 MG-EMTRICITABINE 200 MG-TENOFOVIR ALAFENAM 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 280.51, "gross_charge": 431.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184466", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3101", "type": "HCPCS" }, { "code": "50242-0176-01", "type": "NDC" } ], "description": "TENECTEPLASE 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 20845.4, "gross_charge": 32069.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184474", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "67157-0101-50", "type": "NDC" } ], "description": "ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 24.67, "gross_charge": 37.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184475", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "70727-0497-25", "type": "NDC" } ], "description": "NETARSUDIL 0.02 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 630.56, "gross_charge": 970.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184479", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65628-0205-10", "type": "NDC" } ], "description": "VANCOMYCIN 25 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 8.68, "gross_charge": 13.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184540", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "62327-0444-44", "type": "NDC" } ], "description": "STERILE TALC 4 GRAM INTRAPLEURAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 480.02, "gross_charge": 738.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184759", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90375", "type": "HCPCS" }, { "code": "13533-0318-01", "type": "NDC" } ], "description": "RABIES IMMUNE GLOBULIN (PF) 300 UNIT/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 1510.37, "gross_charge": 2323.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184939", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2272", "type": "HCPCS" }, { "code": "63323-0454-00", "type": "NDC" } ], "description": "MORPHINE 4 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 27.07, "gross_charge": 41.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184945", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00002-4182-30", "type": "NDC" } ], "description": "BARICITINIB 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 173.65, "gross_charge": 267.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184949", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9046", "type": "HCPCS" }, { "code": "64950-0362-04", "type": "NDC" } ], "description": "COCAINE 4 % NASAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 624.55, "gross_charge": 960.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-184963", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "00024-5922-01", "type": "NDC" } ], "description": "SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.14 ML", "billing_class": "facility", "discounted_cash": 7317.21, "gross_charge": 11257.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185021", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2042", "type": "HCPCS" }, { "code": "00078-0958-19", "type": "NDC" } ], "description": "TISAGENLECLEUCEL 0.6 X 10EXP8 TO 6 X10EXP8 CELL INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1331645.8, "gross_charge": 2048685.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185086", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5106", "type": "HCPCS" }, { "code": "00069-1305-10", "type": "NDC" } ], "description": "EPOETIN ALFA-EPBX 2,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 80.99, "gross_charge": 124.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185087", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5106", "type": "HCPCS" }, { "code": "00069-1306-10", "type": "NDC" } ], "description": "EPOETIN ALFA-EPBX 3,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 110.76, "gross_charge": 170.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185088", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5106", "type": "HCPCS" }, { "code": "00069-1307-10", "type": "NDC" } ], "description": "EPOETIN ALFA-EPBX 4,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 140.53, "gross_charge": 216.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185089", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5106", "type": "HCPCS" }, { "code": "00069-1308-10", "type": "NDC" } ], "description": "EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 319.25, "gross_charge": 491.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185090", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5106", "type": "HCPCS" }, { "code": "00069-1309-04", "type": "NDC" } ], "description": "EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 1212.84, "gross_charge": 1865.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185201", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00574-0304-16", "type": "NDC" } ], "description": "COMPOUNDING VEHICLE SYRUP NO.23", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 46.83, "gross_charge": 72.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185449", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5108", "type": "HCPCS" }, { "code": "83257-0005-41", "type": "NDC" } ], "description": "PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 4458.74, "gross_charge": 6859.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185477", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1943", "type": "HCPCS" }, { "code": "65757-0500-03", "type": "NDC" } ], "description": "ARIPIPRAZOLE LAUROXIL,SUBMIC. ER 675 MG/2.4 ML SUSP,EXT.REL.IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.4 ML", "billing_class": "facility", "discounted_cash": 7361.74, "gross_charge": 11325.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185478", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "51754-1029-01", "type": "NDC" } ], "description": "NITROPRUSSIDE 20 MG/100 ML (0.2 MG/ML) IN 0.9% SODIUM CHLORIDE IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 126.88, "gross_charge": 195.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18551", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7305-61", "type": "NDC" } ], "description": "CARVEDILOL 3.125 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185737", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9047", "type": "HCPCS" }, { "code": "76075-0103-01", "type": "NDC" } ], "description": "CARFILZOMIB 10 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1642.91, "gross_charge": 2527.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185746", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00338-0502-06", "type": "NDC" } ], "description": "PARENTERAL AMINO ACID 15 % COMBINATION NO.5 INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2000 ML", "billing_class": "facility", "discounted_cash": 178.65, "gross_charge": 274.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185747", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00310-1105-30", "type": "NDC" } ], "description": "SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 41.83, "gross_charge": 64.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185748", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00310-1110-30", "type": "NDC" } ], "description": "SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 41.83, "gross_charge": 64.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185805", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9204", "type": "HCPCS" }, { "code": "42747-0761-01", "type": "NDC" } ], "description": "MOGAMULIZUMAB-KPKC 4 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 12822.81, "gross_charge": 19727.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-185808", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0222", "type": "HCPCS" }, { "code": "71336-1000-01", "type": "NDC" } ], "description": "PATISIRAN (LIPID COMPLEX) 2 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 26702.78, "gross_charge": 41081.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186011", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5110", "type": "HCPCS" }, { "code": "00069-0291-01", "type": "NDC" } ], "description": "FILGRASTIM-AAFI 300 MCG/0.5 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 297.21, "gross_charge": 457.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186012", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5110", "type": "HCPCS" }, { "code": "00069-0292-10", "type": "NDC" } ], "description": "FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 297.18, "gross_charge": 457.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186041", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0982-55", "type": "NDC" } ], "description": "KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC INJ SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 40.24, "gross_charge": 61.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186072", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0950-10", "type": "NDC" } ], "description": "CALCIUM GLUCONATE 1 GRAM/10 ML (100 MG/ML) IN STERILE WATER IV SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 33.67, "gross_charge": 51.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186087", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00006-3069-01", "type": "NDC" } ], "description": "DORAVIRINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 124.12, "gross_charge": 190.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18621", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59762-0333-02", "type": "NDC" } ], "description": "LATANOPROST 0.005 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 11.86, "gross_charge": 18.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186271", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7527", "type": "HCPCS" }, { "code": "67877-0721-33", "type": "NDC" } ], "description": "EVEROLIMUS (IMMUNOSUPPRESSIVE) 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 33.34, "gross_charge": 51.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186275", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "63600107", "type": "HCPCS" }, { "code": "71469-0231-01", "type": "NDC" } ], "description": "AMINOLEVULINIC ACID HCL 30 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6526.03, "gross_charge": 10040.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186280", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50458-0577-10", "type": "NDC" } ], "description": "RIVAROXABAN 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.06, "gross_charge": 26.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-186906", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5111", "type": "HCPCS" }, { "code": "70114-0101-01", "type": "NDC" } ], "description": "PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 5726.56, "gross_charge": 8810.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187113", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "54288-0105-15", "type": "NDC" } ], "description": "ETHYL ALCOHOL 99 % INTRA-ARTERIAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 1828.45, "gross_charge": 2813.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187129", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "14537-0967-75", "type": "NDC" } ], "description": "DEXTROSE 2.45 GRAM-SOD CITRATE 2.2 GRAM-CITRIC AC 800 MG/100 ML SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 750 ML", "billing_class": "facility", "discounted_cash": 91.32, "gross_charge": 140.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187160", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7169", "type": "HCPCS" }, { "code": "69853-0102-01", "type": "NDC" } ], "description": "FACTOR XA,INACTIVATED-ZHZO (RECOMBINANT) 200 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6794.0, "gross_charge": 10452.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187340", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9047", "type": "HCPCS" }, { "code": "58468-0227-01", "type": "NDC" } ], "description": "CAPLACIZUMAB-YHDP 11 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23164.9, "gross_charge": 35638.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187341", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9047", "type": "HCPCS" }, { "code": "58468-0225-01", "type": "NDC" } ], "description": "CAPLACIZUMAB-YHDP 11 MG INJECTION KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23164.9, "gross_charge": 35638.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187478", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9269", "type": "HCPCS" }, { "code": "72187-0401-01", "type": "NDC" } ], "description": "TAGRAXOFUSP-ERZS 1,000 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 91070.23, "gross_charge": 140108.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187541", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9022", "type": "HCPCS" }, { "code": "50242-0918-01", "type": "NDC" } ], "description": "ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 ML", "billing_class": "facility", "discounted_cash": 21926.97, "gross_charge": 33733.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187713", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9356", "type": "HCPCS" }, { "code": "50242-0077-01", "type": "NDC" } ], "description": "TRASTUZUMAB 600 MG-HYALURONIDASE-OYSK 10,000 UNIT/5 ML SUBCUT SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 12659.04, "gross_charge": 19475.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187753", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3111", "type": "HCPCS" }, { "code": "55513-0880-02", "type": "NDC" } ], "description": "ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.34 ML", "billing_class": "facility", "discounted_cash": 7141.65, "gross_charge": 10987.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187771", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00264-4500-00", "type": "NDC" } ], "description": "PARENTERAL AMINO ACID 15 % COMBINATION NO.6 INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 184.6, "gross_charge": 284.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18786", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0292-01", "type": "NDC" } ], "description": "DONEPEZIL 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18787", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0303-01", "type": "NDC" } ], "description": "DONEPEZIL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-187934", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0651", "type": "HCPCS" }, { "code": "63323-0885-14", "type": "NDC" } ], "description": "LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 236.5, "gross_charge": 363.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-188446", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5107", "type": "HCPCS" }, { "code": "55513-0206-01", "type": "NDC" } ], "description": "BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 1855.1, "gross_charge": 2854.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-188563", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "73177-0109-13", "type": "NDC" } ], "description": "ROPIVACAINE(PF) 0.2 %-0.9 % NACL 545ML INFIL,HI VAR RATE,PCA,ELAS PUMP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 545 ML", "billing_class": "facility", "discounted_cash": 448.11, "gross_charge": 689.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18877", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0252-86", "type": "NDC" } ], "description": "ONDANSETRON HCL 4 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 33.18, "gross_charge": 51.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-188791", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3290", "type": "HCPCS" }, { "code": "80830-2329-02", "type": "NDC" } ], "description": "TRANEXAMIC ACID 1,000 MG/100 ML(10 MG/ML)IN SOD CHLOR,ISO IV PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 36.14, "gross_charge": 55.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-188805", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "73177-0109-20", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 0.2 %-0.9 % NACL 745 ML INFIL,LOW VAR RATE ELAST PUMP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 745 ML", "billing_class": "facility", "discounted_cash": 604.7, "gross_charge": 930.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189017", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7198", "type": "HCPCS" }, { "code": "64193-0426-02", "type": "NDC" } ], "description": "ANTI-INHIBITOR COAGULANT COMPLEX 350 UNIT-650 UNIT INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2857.46, "gross_charge": 4396.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189018", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7198", "type": "HCPCS" }, { "code": "64193-0424-02", "type": "NDC" } ], "description": "ANTI-INHIBITOR COAGULANT COMPLEX 700 UNIT-1,300 UNIT INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5661.6, "gross_charge": 8710.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189021", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "00338-0126-12", "type": "NDC" } ], "description": "INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 78.23, "gross_charge": 120.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18908", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "72485-0105-01", "type": "NDC" } ], "description": "SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 57.59, "gross_charge": 88.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189100", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00169-4303-99", "type": "NDC" } ], "description": "SEMAGLUTIDE 3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2.99, "gross_charge": 4.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18918", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6351-61", "type": "NDC" } ], "description": "LEVOFLOXACIN 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18919", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6352-61", "type": "NDC" } ], "description": "LEVOFLOXACIN 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18920", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0342-01", "type": "NDC" } ], "description": "TOPIRAMATE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-18922", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0344-01", "type": "NDC" } ], "description": "TOPIRAMATE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189403", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5117", "type": "HCPCS" }, { "code": "55513-0141-01", "type": "NDC" } ], "description": "TRASTUZUMAB-ANNS 150 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3565.48, "gross_charge": 5485.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189594", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5114", "type": "HCPCS" }, { "code": "83257-0004-12", "type": "NDC" } ], "description": "TRASTUZUMAB-DKST 420 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5334.88, "gross_charge": 8207.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189595", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5115", "type": "HCPCS" }, { "code": "63459-0104-50", "type": "NDC" } ], "description": "RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 8074.2, "gross_charge": 12421.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189667", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0896", "type": "HCPCS" }, { "code": "59572-0711-01", "type": "NDC" } ], "description": "LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 13361.3, "gross_charge": 20555.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189668", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0896", "type": "HCPCS" }, { "code": "59572-0775-01", "type": "NDC" } ], "description": "LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 40040.94, "gross_charge": 61601.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189687", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0791", "type": "HCPCS" }, { "code": "00078-0883-61", "type": "NDC" } ], "description": "CRIZANLIZUMAB-TMCA 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 6667.15, "gross_charge": 10257.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189700", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2802", "type": "HCPCS" }, { "code": "55513-0223-01", "type": "NDC" } ], "description": "ROMIPLOSTIM 125 MCG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4485.84, "gross_charge": 6901.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189874", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "63323-0254-10", "type": "NDC" } ], "description": "MINERAL OIL, LIGHT STERILE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 45.76, "gross_charge": 70.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189953", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9177", "type": "HCPCS" }, { "code": "51144-0020-01", "type": "NDC" } ], "description": "ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7627.16, "gross_charge": 11734.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189954", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9177", "type": "HCPCS" }, { "code": "51144-0030-01", "type": "NDC" } ], "description": "ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11414.06, "gross_charge": 17560.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-189958", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9358", "type": "HCPCS" }, { "code": "65597-0406-01", "type": "NDC" } ], "description": "FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8375.32, "gross_charge": 12885.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190109", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5118", "type": "HCPCS" }, { "code": "00069-0342-01", "type": "NDC" } ], "description": "BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16 ML", "billing_class": "facility", "discounted_cash": 5497.05, "gross_charge": 8457.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190109", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5118", "type": "HCPCS" }, { "code": "00069-0315-01", "type": "NDC" } ], "description": "BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 1414.27, "gross_charge": 2175.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190111", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5119", "type": "HCPCS" }, { "code": "00069-0238-01", "type": "NDC" } ], "description": "RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 1579.47, "gross_charge": 2429.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190111", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5119", "type": "HCPCS" }, { "code": "00069-0249-01", "type": "NDC" } ], "description": "RITUXIMAB-PVVR 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 7683.91, "gross_charge": 11821.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190210", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3241", "type": "HCPCS" }, { "code": "75987-0130-15", "type": "NDC" } ], "description": "TEPROTUMUMAB-TRBW 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 48637.22, "gross_charge": 74826.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190358", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0699", "type": "HCPCS" }, { "code": "59630-0266-01", "type": "NDC" } ], "description": "CEFIDEROCOL 1 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 723.26, "gross_charge": 1112.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190565", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "71699-0050-30", "type": "NDC" } ], "description": "CENOBAMATE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 79.07, "gross_charge": 121.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190568", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "71699-0200-30", "type": "NDC" } ], "description": "CENOBAMATE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 79.07, "gross_charge": 121.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190599", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "72618-3000-02", "type": "NDC" } ], "description": "RIMEGEPANT 75 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 244.56, "gross_charge": 376.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190609", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9227", "type": "HCPCS" }, { "code": "00024-0656-01", "type": "NDC" } ], "description": "ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 11781.02, "gross_charge": 18124.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190609", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9227", "type": "HCPCS" }, { "code": "00024-0654-01", "type": "NDC" } ], "description": "ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 2398.89, "gross_charge": 3690.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-190917", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9317", "type": "HCPCS" }, { "code": "55135-0132-01", "type": "NDC" } ], "description": "SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6965.24, "gross_charge": 10715.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-191088", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24338-0230-12", "type": "NDC" } ], "description": "NIMODIPINE 30 MG/5 ML ORAL SYRINGE (FOR ORAL USE ONLY)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 94.35, "gross_charge": 145.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-191098", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9144", "type": "HCPCS" }, { "code": "57894-0503-01", "type": "NDC" } ], "description": "DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 28415.4, "gross_charge": 43716.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-191439", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1823", "type": "HCPCS" }, { "code": "75987-0150-03", "type": "NDC" } ], "description": "INEBILIZUMAB-CDON 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 378200.52, "gross_charge": 581846.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-191443", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9223", "type": "HCPCS" }, { "code": "68727-0712-01", "type": "NDC" } ], "description": "LURBINECTEDIN 4 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 22297.54, "gross_charge": 34303.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-191683", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9316", "type": "HCPCS" }, { "code": "50242-0245-01", "type": "NDC" } ], "description": "PERTUZUMAB 1,200 MG-TRASTUZUMAB 600 MG-HYALURON-ZZXF/15 ML SUBCUT SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 37576.01, "gross_charge": 57809.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19176", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0097-01", "type": "NDC" } ], "description": "ATORVASTATIN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19177", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0099-01", "type": "NDC" } ], "description": "ATORVASTATIN 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19178", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0098-01", "type": "NDC" } ], "description": "ATORVASTATIN 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19179", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0833-05", "type": "NDC" } ], "description": "AZELASTINE 137 MCG (0.1 %) NASAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 37.9, "gross_charge": 58.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19180", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" }, { "code": "00002-8501-01", "type": "NDC" } ], "description": "INSULIN REGULAR HUMAN U-500(CONCENTRATE) 500 UNIT/ML SUBCUTANEOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 4458.8, "gross_charge": 6859.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-191994", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9073", "type": "HCPCS" }, { "code": "50742-0521-10", "type": "NDC" } ], "description": "CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 1168.47, "gross_charge": 1797.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192004", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9349", "type": "HCPCS" }, { "code": "50881-0013-03", "type": "NDC" } ], "description": "TAFASITAMAB-CXIX 200 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3817.0, "gross_charge": 5872.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192019", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" }, { "code": "64281-0114-00", "type": "NDC" } ], "description": "METHACHOLINE CHLORIDE 3 MG/3 ML (1 MG/ML) NEBULIZATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 10.04, "gross_charge": 15.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192020", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" }, { "code": "64281-0115-00", "type": "NDC" } ], "description": "METHACHOLINE CHLORIDE 12 MG/3 ML (4 MG/ML) NEBULIZATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 10.04, "gross_charge": 15.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192021", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" }, { "code": "64281-0116-00", "type": "NDC" } ], "description": "METHACHOLINE CHLORIDE 48 MG/3 ML (16 MG/ML) NEBULIZATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 10.04, "gross_charge": 15.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192023", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" }, { "code": "64281-0112-00", "type": "NDC" } ], "description": "METHACHOLINE CHLORIDE 0.1875 MG/3 ML (0.0625 MG/ML) NEBULIZATION SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 10.04, "gross_charge": 15.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192024", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" }, { "code": "64281-0113-00", "type": "NDC" } ], "description": "METHACHOLINE CHLORIDE 0.75 MG/3 ML (0.25 MG/ML) NEBULIZATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 10.04, "gross_charge": 15.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192080", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "64281-0111-00", "type": "NDC" } ], "description": "METHACHOLINE CHLORIDE 0 MG/3 ML (0 MG/ML) NEBULIZATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 10.04, "gross_charge": 15.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19226", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8515", "type": "HCPCS" }, { "code": "23155-0823-73", "type": "NDC" } ], "description": "CABERGOLINE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.73, "gross_charge": 10.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192261", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90619", "type": "HCPCS" }, { "code": "49281-0590-58", "type": "NDC" } ], "description": "MENINGOCOCCAL VAC A,C,Y,W-135,CONJ TET (PF) 10 MCG/0.5 ML IM SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 399.75, "gross_charge": 615.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192265", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00517-9305-01", "type": "NDC" } ], "description": "TRACE ELEMENTS ZN 3 MG-CU 0.3 MG-MN 55 MCG-SE 60 MCG/ML IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 97.6, "gross_charge": 150.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192312", "type": "CDM" }, { "code": "343", "type": "RC" }, { "code": "A9592", "type": "HCPCS" }, { "code": "69945-0064-01", "type": "NDC" } ], "description": "COPPER CU-64 DOTATATE 148 MBQ/4 ML (4 MCI/4 ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 7800.0, "gross_charge": 12000.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192326", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-1434-01", "type": "NDC" } ], "description": "DEXMEDETOMIDINE 1,000 MCG/250 ML(4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 143.06, "gross_charge": 220.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192581", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00173-0893-10", "type": "NDC" } ], "description": "FLUTICASONE FUR. 200 MCG-UMECLID 62.5 MCG-VILANT 25 MCG INHALAT.POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.21, "gross_charge": 37.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192625", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1303", "type": "HCPCS" }, { "code": "25682-0028-01", "type": "NDC" } ], "description": "RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 11 ML", "billing_class": "facility", "discounted_cash": 64631.52, "gross_charge": 99433.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-192625", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1303", "type": "HCPCS" }, { "code": "25682-0025-01", "type": "NDC" } ], "description": "RAVULIZUMAB-CWVZ 100 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 17665.57, "gross_charge": 27177.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-193027", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5106", "type": "HCPCS" }, { "code": "00069-1311-10", "type": "NDC" } ], "description": "EPOETIN ALFA-EPBX 20,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 617.11, "gross_charge": 949.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19333", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0735", "type": "HCPCS" }, { "code": "39822-2000-01", "type": "NDC" } ], "description": "CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EPIDURAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.5 ML", "billing_class": "facility", "discounted_cash": 29.22, "gross_charge": 44.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-193653", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2054", "type": "HCPCS" }, { "code": "73153-0900-01", "type": "NDC" } ], "description": "LISOCABTAGENE MARALEUCEL 1.5 X 10EXP6 TO 70 X 10EXP6 CELL/ML IV SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1328515.18, "gross_charge": 2043869.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-193873", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2054", "type": "HCPCS" }, { "code": "73153-0901-08", "type": "NDC" } ], "description": "LISOCABTAGENE MARALEUCEL(CD8) 1.5X TO 70X 10EXP6 CELL/ML IV SUSP(1OF2)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1327698.12, "gross_charge": 2042612.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-193874", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2054", "type": "HCPCS" }, { "code": "73153-0902-04", "type": "NDC" } ], "description": "LISOCABTAGENE MARALEUCEL(CD4) 1.5X TO 70X 10EXP6 CELL/ML IV SUSP(2OF2)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1327698.12, "gross_charge": 2042612.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-194047", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2055", "type": "HCPCS" }, { "code": "59572-0515-01", "type": "NDC" } ], "description": "IDECABTAGENE VICLEUCEL 300 X 10EXP6 TO 510 X 10EXP6 CELL IV SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1357467.41, "gross_charge": 2088411.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-194269", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3240", "type": "HCPCS" }, { "code": "58468-0030-02", "type": "NDC" } ], "description": "THYROTROPIN ALFA 0.9 MG INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6977.1, "gross_charge": 10734.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-194274", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0391", "type": "HCPCS" }, { "code": "73607-0011-11", "type": "NDC" } ], "description": "ARTESUNATE 110 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15805.66, "gross_charge": 24316.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19433", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-1214-00", "type": "NDC" } ], "description": "WARFARIN 3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19434", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-1217-00", "type": "NDC" } ], "description": "WARFARIN 6 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-194713", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0668", "type": "HCPCS" }, { "code": "47426-0501-02", "type": "NDC" } ], "description": "BUPIVACAINE-MELOXICAM ER 400 MG-12 MG/14 ML SURGICAL SITE INSTILL SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7 ML", "billing_class": "facility", "discounted_cash": 495.01, "gross_charge": 761.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19483", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-5460-72", "type": "NDC" } ], "description": "CALCIUM 500 MG (AS CARBONATE)-VITAMIN D3 5 MCG (200 UNIT) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-195234", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90677", "type": "HCPCS" }, { "code": "00005-2000-10", "type": "NDC" } ], "description": "PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 737.88, "gross_charge": 1135.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-195447", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0491", "type": "HCPCS" }, { "code": "00310-3040-00", "type": "NDC" } ], "description": "ANIFROLUMAB-FNIA 300 MG/2 ML (150 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 17666.71, "gross_charge": 27179.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-195685", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "74300-0010-67", "type": "NDC" } ], "description": "POLYETHYLENE GLYCOL 400 1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-195747", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9273", "type": "HCPCS" }, { "code": "51144-0003-01", "type": "NDC" } ], "description": "TISOTUMAB VEDOTIN-TFTV 40 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 20007.88, "gross_charge": 30781.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-195911", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2053", "type": "HCPCS" }, { "code": "71287-0220-01", "type": "NDC" } ], "description": "BREXUCABTAGENE AUTOLEUCEL 1X 10EXP6 TO 1X 10EXP8 CELL IV SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1258310.33, "gross_charge": 1935862.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-196401", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9332", "type": "HCPCS" }, { "code": "73475-3041-05", "type": "NDC" } ], "description": "EFGARTIGIMOD ALFA-FCAB 20 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 20499.86, "gross_charge": 31538.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-196786", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2598", "type": "HCPCS" }, { "code": "42023-0237-01", "type": "NDC" } ], "description": "VASOPRESSIN 0.2 UNIT/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 111.83, "gross_charge": 172.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-196983", "type": "CDM" }, { "code": "891", "type": "RC" }, { "code": "Q2056", "type": "HCPCS" }, { "code": "57894-0111-01", "type": "NDC" } ], "description": "CILTACABTAGENE AUTOLEUCEL 0.5 X 10EXP6 TO 1X 10EXP8 CELL IV SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1421871.49, "gross_charge": 2187494.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-197056", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00074-1043-28", "type": "NDC" } ], "description": "UPADACITINIB ER 45 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 891.96, "gross_charge": 1372.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-197064", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9298", "type": "HCPCS" }, { "code": "00003-7125-11", "type": "NDC" } ], "description": "NIVOLUMAB 240 MG-RELATLIMAB-RMBW 80 MG/20 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 41635.1, "gross_charge": 64054.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19711", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59762-3744-01", "type": "NDC" } ], "description": "CLINDAMYCIN 1 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 245.99, "gross_charge": 378.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19713", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "13517-0100-30", "type": "NDC" } ], "description": "DIAZOXIDE 50 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 553.57, "gross_charge": 851.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19733", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0126-05", "type": "NDC" } ], "description": "KETOROLAC 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 75.79, "gross_charge": 116.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19736", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1050", "type": "HCPCS" }, { "code": "00009-0746-30", "type": "NDC" } ], "description": "MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 180.05, "gross_charge": 277.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-197381", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00069-5434-02", "type": "NDC" } ], "description": "NIRMATRELVIR 150 MG (10)-RITONAVIR 100 MG (10) TABLETS IN A DOSE PACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 143.49, "gross_charge": 220.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19749", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00037-6823-15", "type": "NDC" } ], "description": "PRAMOXINE 1 % TOPICAL FOAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 232.7, "gross_charge": 358.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19770", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0045-01", "type": "NDC" } ], "description": "TRIAMCINOLONE ACETONIDE 0.147 MG/GRAM TOPICAL AEROSOL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 63 GR", "billing_class": "facility", "discounted_cash": 493.94, "gross_charge": 759.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19779", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "58980-0608-80", "type": "NDC" } ], "description": "UREA 10 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 236 ML", "billing_class": "facility", "discounted_cash": 21.68, "gross_charge": 33.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19779", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "38485-0980-18", "type": "NDC" } ], "description": "UREA 10 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 240 ML", "billing_class": "facility", "discounted_cash": 27.17, "gross_charge": 41.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-197839", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9294", "type": "HCPCS" }, { "code": "00409-2188-01", "type": "NDC" } ], "description": "PEMETREXED DISODIUM 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 213.59, "gross_charge": 328.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-197839", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9294", "type": "HCPCS" }, { "code": "00409-1045-01", "type": "NDC" } ], "description": "PEMETREXED DISODIUM 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 115.9, "gross_charge": 178.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-197867", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0225", "type": "HCPCS" }, { "code": "71336-1003-01", "type": "NDC" } ], "description": "VUTRISIRAN 25 MG/0.5 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 325105.79, "gross_charge": 500162.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-197875", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2327", "type": "HCPCS" }, { "code": "00074-5015-01", "type": "NDC" } ], "description": "RISANKIZUMAB-RZAA 60 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 28068.59, "gross_charge": 43182.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19805", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00168-0323-46", "type": "NDC" } ], "description": "METRONIDAZOLE 0.75 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 45 GR", "billing_class": "facility", "discounted_cash": 175.47, "gross_charge": 269.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-198515", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "73177-0101-02", "type": "NDC" } ], "description": "KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC IV SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 41.08, "gross_charge": 63.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19882", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0231-01", "type": "NDC" } ], "description": "SERTRALINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-199160", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9380", "type": "HCPCS" }, { "code": "57894-0450-01", "type": "NDC" } ], "description": "TECLISTAMAB-CQYV 90 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.7 ML", "billing_class": "facility", "discounted_cash": 28222.74, "gross_charge": 43419.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-199161", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9380", "type": "HCPCS" }, { "code": "57894-0449-01", "type": "NDC" } ], "description": "TECLISTAMAB-CQYV 10 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 5576.74, "gross_charge": 8579.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-19928", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0006-31", "type": "NDC" } ], "description": "ITRACONAZOLE 10 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 150 ML", "billing_class": "facility", "discounted_cash": 508.92, "gross_charge": 782.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-199649", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9350", "type": "HCPCS" }, { "code": "50242-0159-01", "type": "NDC" } ], "description": "MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 1736.51, "gross_charge": 2671.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-199649", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9350", "type": "HCPCS" }, { "code": "50242-0142-01", "type": "NDC" } ], "description": "MOSUNETUZUMAB-AXGB 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 50548.1, "gross_charge": 77766.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-199840", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2329", "type": "HCPCS" }, { "code": "73150-0150-06", "type": "NDC" } ], "description": "UBLITUXIMAB-XIIY 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 30008.84, "gross_charge": 46167.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2007", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3420", "type": "HCPCS" }, { "code": "71288-0303-02", "type": "NDC" } ], "description": "CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 21.68, "gross_charge": 33.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2008", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0852-15", "type": "NDC" } ], "description": "CYANOCOBALAMIN (VIT B-12) 100 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2009", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "54629-0586-05", "type": "NDC" } ], "description": "CYANOCOBALAMIN (VIT B-12) 1,000 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2010", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0853-11", "type": "NDC" } ], "description": "CYANOCOBALAMIN (VIT B-12) 250 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-201038", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0163", "type": "HCPCS" }, { "code": "42023-0315-01", "type": "NDC" } ], "description": "EPINEPHRINE 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 118.56, "gross_charge": 182.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-201188", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9321", "type": "HCPCS" }, { "code": "82705-0010-01", "type": "NDC" } ], "description": "EPCORITAMAB-BYSP 48 MG/0.8 ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 44488.6, "gross_charge": 68444.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-201189", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9321", "type": "HCPCS" }, { "code": "82705-0002-01", "type": "NDC" } ], "description": "EPCORITAMAB-BYSP 4 MG/0.8 ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 3756.32, "gross_charge": 5778.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2012", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "77333-0937-10", "type": "NDC" } ], "description": "CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-201546", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9286", "type": "HCPCS" }, { "code": "50242-0127-01", "type": "NDC" } ], "description": "GLOFITAMAB-GXBM 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 29284.42, "gross_charge": 45052.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-201546", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9286", "type": "HCPCS" }, { "code": "50242-0125-01", "type": "NDC" } ], "description": "GLOFITAMAB-GXBM 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 7361.09, "gross_charge": 11324.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-20156", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9100", "type": "HCPCS" }, { "code": "63323-0120-20", "type": "NDC" } ], "description": "CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 84.56, "gross_charge": 130.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2017", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0558-01", "type": "NDC" } ], "description": "CYCLOBENZAPRINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-201784", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90678", "type": "HCPCS" }, { "code": "00069-0344-01", "type": "NDC" } ], "description": "RESP SYNCYTIAL VIRUS VAC, PREF A AND B (PF) 120 MCG/0.5 ML IM SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 844.45, "gross_charge": 1299.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-202140", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3055", "type": "HCPCS" }, { "code": "57894-0470-01", "type": "NDC" } ], "description": "TALQUETAMAB-TGVS 40 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 31203.38, "gross_charge": 48005.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-202141", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3055", "type": "HCPCS" }, { "code": "57894-0469-01", "type": "NDC" } ], "description": "TALQUETAMAB-TGVS 2 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.5 ML", "billing_class": "facility", "discounted_cash": 2389.63, "gross_charge": 3676.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-202169", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1323", "type": "HCPCS" }, { "code": "00069-2522-02", "type": "NDC" } ], "description": "ELRANATAMAB-BCMM 40 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 6135.32, "gross_charge": 9438.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-202169", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1323", "type": "HCPCS" }, { "code": "00069-4494-02", "type": "NDC" } ], "description": "ELRANATAMAB-BCMM 40 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 6135.32, "gross_charge": 9438.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2025", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0735-01", "type": "NDC" } ], "description": "CYCLOPENTOLATE 1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 35.94, "gross_charge": 55.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-202948", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2183", "type": "HCPCS" }, { "code": "44567-0402-01", "type": "NDC" } ], "description": "MEROPENEM 2 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 104.29, "gross_charge": 160.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-203004", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3263", "type": "HCPCS" }, { "code": "70114-0340-01", "type": "NDC" } ], "description": "TORIPALIMAB-TPZI 240 MG/6 ML (40 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 25728.59, "gross_charge": 39582.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2033", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0190-01", "type": "NDC" } ], "description": "CYPROHEPTADINE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-203439", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "81284-0831-05", "type": "NDC" } ], "description": "PHYSOSTIGMINE 0.4 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 430.88, "gross_charge": 662.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-203448", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0645-13", "type": "NDC" } ], "description": "CAMPHOR 3.1 %-METHYL SALICYLATE 10 %-MENTHOL 6 % TOPICAL PATCH (LARGE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.39, "gross_charge": 0.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-203546", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q5111", "type": "HCPCS" }, { "code": "70114-0130-01", "type": "NDC" } ], "description": "PEGFILGRASTIM-CBQV 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUT INJECTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 10794.65, "gross_charge": 16607.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-203560", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "00409-1805-10", "type": "NDC" } ], "description": "HYDROMORPHONE 0.25 MG/0.5 ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 29.64, "gross_charge": 45.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-203965", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1230", "type": "HCPCS" }, { "code": "73177-0161-43", "type": "NDC" } ], "description": "METHADONE 10 MG/ML IN SODIUM CHLORIDE,ISO-OSMOTIC INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 738.08, "gross_charge": 1135.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-20446", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "13668-0453-01", "type": "NDC" } ], "description": "ANAGRELIDE 0.5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.58, "gross_charge": 7.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-204538", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "73177-0155-27", "type": "NDC" } ], "description": "KETAMINE (PF) 5 MG/ML IN SODIUM CHLORIDE, ISO-OSMOTIC IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 120.25, "gross_charge": 185.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-20472", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00143-9506-10", "type": "NDC" } ], "description": "ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 27.04, "gross_charge": 41.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-20566", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0525-15", "type": "NDC" } ], "description": "MELOXICAM 7.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-20580", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0199-11", "type": "NDC" } ], "description": "MELOXICAM 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-207741", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42806-0270-98", "type": "NDC" } ], "description": "CHOLESTYRAMINE 4 GRAM ORAL POWDER FOR SUSPENSION IN A PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.68, "gross_charge": 7.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-20887", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00143-9637-01", "type": "NDC" } ], "description": "VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 28.63, "gross_charge": 44.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-208900", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-9540-07", "type": "NDC" } ], "description": "OLIVE, SOYBEAN OIL FAT EMULSION 20 % INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 42.7, "gross_charge": 65.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-209277", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90662", "type": "HCPCS" }, { "code": "49281-0125-65", "type": "NDC" } ], "description": "FLU VACCINE TS2025-26(65YR UP)(PF)180 MCG/0.5 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 303.88, "gross_charge": 467.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-209281", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90656", "type": "HCPCS" }, { "code": "49281-0425-88", "type": "NDC" } ], "description": "FLU VACCINE TS 2025-26(6MOS UP)(PF) 45 MCG(15MCG X3)/0.5 ML IM SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 89.8, "gross_charge": 138.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-20954", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1955", "type": "HCPCS" }, { "code": "54482-0147-01", "type": "NDC" } ], "description": "LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 138.58, "gross_charge": 213.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21044", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1950", "type": "HCPCS" }, { "code": "00074-3663-03", "type": "NDC" } ], "description": "LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14291.19, "gross_charge": 21986.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21045", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" }, { "code": "00074-3346-03", "type": "NDC" } ], "description": "LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1453.11, "gross_charge": 2235.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21057", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0525-01", "type": "NDC" } ], "description": "OLANZAPINE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21061", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0722-11", "type": "NDC" } ], "description": "OXCARBAZEPINE 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.26, "gross_charge": 6.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21062", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6085-61", "type": "NDC" } ], "description": "CITALOPRAM 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21063", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0456", "type": "HCPCS" }, { "code": "25021-0180-66", "type": "NDC" } ], "description": "AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 30.19, "gross_charge": 46.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21108", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" }, { "code": "00074-3683-03", "type": "NDC" } ], "description": "LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1919.64, "gross_charge": 2953.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21135", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "47335-0788-91", "type": "NDC" } ], "description": "DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY (NON-REFRIGERATED)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 327.7, "gross_charge": 504.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2120", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00527-1369-01", "type": "NDC" } ], "description": "DANAZOL 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.3, "gross_charge": 14.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21287", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "13668-0091-90", "type": "NDC" } ], "description": "PRAMIPEXOLE 0.125 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21290", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0570-01", "type": "NDC" } ], "description": "PRAMIPEXOLE 0.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21300", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0033-06", "type": "NDC" } ], "description": "PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.8, "gross_charge": 5.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2131", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70954-0136-10", "type": "NDC" } ], "description": "DAPSONE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.26, "gross_charge": 8.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2132", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70954-0135-20", "type": "NDC" } ], "description": "DAPSONE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.65, "gross_charge": 7.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21372", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65162-0765-10", "type": "NDC" } ], "description": "WARFARIN 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21374", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7517", "type": "HCPCS" }, { "code": "60687-0438-01", "type": "NDC" } ], "description": "MYCOPHENOLATE MOFETIL 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.22, "gross_charge": 6.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21509", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0476-15", "type": "NDC" } ], "description": "LETROZOLE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21672", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "24338-0050-08", "type": "NDC" } ], "description": "CARMUSTINE IN POLIFEPROSAN 7.7 MG WAFER FOR IMPLANT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14433.41, "gross_charge": 22205.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21688", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0577-01", "type": "NDC" } ], "description": "ROPINIROLE 0.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21689", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0588-01", "type": "NDC" } ], "description": "ROPINIROLE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21690", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62332-0033-31", "type": "NDC" } ], "description": "ROPINIROLE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21800", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0254-01", "type": "NDC" } ], "description": "ROPINIROLE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21810", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0506-60", "type": "NDC" } ], "description": "LAMIVUDINE 150 MG-ZIDOVUDINE 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.4, "gross_charge": 8.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21823", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0327-01", "type": "NDC" } ], "description": "QUETIAPINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21824", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0349-01", "type": "NDC" } ], "description": "QUETIAPINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21825", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0360-01", "type": "NDC" } ], "description": "QUETIAPINE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21827", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-5031-56", "type": "NDC" } ], "description": "TIAGABINE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14.92, "gross_charge": 22.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21880", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0476", "type": "HCPCS" }, { "code": "70257-0562-55", "type": "NDC" } ], "description": "BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 70.52, "gross_charge": 108.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-21900", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0289", "type": "HCPCS" }, { "code": "62756-0233-01", "type": "NDC" } ], "description": "AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 268.58, "gross_charge": 413.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22120", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90675", "type": "HCPCS" }, { "code": "50632-0010-01", "type": "NDC" } ], "description": "RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 875.16, "gross_charge": 1346.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22142", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0536-01", "type": "NDC" } ], "description": "CLOPIDOGREL 75 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22149", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9312", "type": "HCPCS" }, { "code": "50242-0051-21", "type": "NDC" } ], "description": "RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 2586.54, "gross_charge": 3979.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22149", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9312", "type": "HCPCS" }, { "code": "50242-0053-06", "type": "NDC" } ], "description": "RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 12719.4, "gross_charge": 19568.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22150", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0100-53", "type": "NDC" } ], "description": "NICOTINE 10 MG INHALATION CARTRIDGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.9, "gross_charge": 13.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22185", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1451", "type": "HCPCS" }, { "code": "25021-0829-02", "type": "NDC" } ], "description": "FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.5 ML", "billing_class": "facility", "discounted_cash": 1603.91, "gross_charge": 2467.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22240", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "42571-0408-92", "type": "NDC" } ], "description": "TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 13.2, "gross_charge": 20.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22251", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-1370-02", "type": "NDC" } ], "description": "MUPIROCIN CALCIUM 2 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 80.21, "gross_charge": 123.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22257", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0410-05", "type": "NDC" } ], "description": "OFLOXACIN 0.3 % EAR DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 327.8, "gross_charge": 504.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22289", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0699-21", "type": "NDC" } ], "description": "CEFDINIR 300 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.96, "gross_charge": 12.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22290", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-4136-64", "type": "NDC" } ], "description": "CEFDINIR 125 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 12 ML", "billing_class": "facility", "discounted_cash": 17.39, "gross_charge": 26.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22472", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1885", "type": "HCPCS" }, { "code": "63323-0161-12", "type": "NDC" } ], "description": "KETOROLAC 15 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 23.43, "gross_charge": 36.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22473", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1885", "type": "HCPCS" }, { "code": "63323-0162-23", "type": "NDC" } ], "description": "KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 23.5, "gross_charge": 36.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22509", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0875-01", "type": "NDC" } ], "description": "MONTELUKAST 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22560", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70954-0258-10", "type": "NDC" } ], "description": "SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.31, "gross_charge": 11.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22586", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0954-95", "type": "NDC" } ], "description": "REPAGLINIDE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.86, "gross_charge": 12.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22588", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0348-01", "type": "NDC" } ], "description": "LOSARTAN 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.84, "gross_charge": 5.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22719", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0581-21", "type": "NDC" } ], "description": "PRAMIPEXOLE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.22, "gross_charge": 6.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2284", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0116-01", "type": "NDC" } ], "description": "DESIPRAMINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.96, "gross_charge": 6.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2286", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0113-01", "type": "NDC" } ], "description": "DESIPRAMINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2291", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "72578-0086-01", "type": "NDC" } ], "description": "DESONIDE 0.05 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 30.32, "gross_charge": 46.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22959", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0402-05", "type": "NDC" } ], "description": "PAROXETINE 10 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 20.93, "gross_charge": 32.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22981", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0287", "type": "HCPCS" }, { "code": "57665-0101-41", "type": "NDC" } ], "description": "AMPHOTERICIN B LIPID COMPLEX 5 MG/ML INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 337.94, "gross_charge": 519.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22982", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0030-02", "type": "NDC" } ], "description": "DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 55.74, "gross_charge": 85.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22992", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0781-11", "type": "NDC" } ], "description": "AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.27, "gross_charge": 15.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-22993", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8522", "type": "HCPCS" }, { "code": "00093-7473-06", "type": "NDC" } ], "description": "CAPECITABINE 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.3, "gross_charge": 8.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23049", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3246", "type": "HCPCS" }, { "code": "25208-0901-04", "type": "NDC" } ], "description": "TIROFIBAN 250 MCG/ML CONCENTRATE,INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 102.76, "gross_charge": 158.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23050", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3246", "type": "HCPCS" }, { "code": "25208-0902-01", "type": "NDC" } ], "description": "TIROFIBAN 5 MG/100 ML (50 MCG/ML)-0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 119.54, "gross_charge": 183.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23063", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0573-10", "type": "NDC" } ], "description": "CAMPHOR-MENTHOL 0.5 %-0.5 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 222 ML", "billing_class": "facility", "discounted_cash": 12.25, "gross_charge": 18.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2320", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8540", "type": "HCPCS" }, { "code": "00054-3177-63", "type": "NDC" } ], "description": "DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.01, "gross_charge": 9.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2322", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8540", "type": "HCPCS" }, { "code": "00054-4179-25", "type": "NDC" } ], "description": "DEXAMETHASONE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2326", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8540", "type": "HCPCS" }, { "code": "00054-8176-25", "type": "NDC" } ], "description": "DEXAMETHASONE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.16, "gross_charge": 6.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2327", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8540", "type": "HCPCS" }, { "code": "00054-8175-25", "type": "NDC" } ], "description": "DEXAMETHASONE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.91, "gross_charge": 7.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2331", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00641-0367-21", "type": "NDC" } ], "description": "DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.65, "gross_charge": 34.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2332", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00641-6145-25", "type": "NDC" } ], "description": "DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.3, "gross_charge": 34.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2335", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "24208-0720-02", "type": "NDC" } ], "description": "DEXAMETHASONE SODIUM PHOSPHATE 0.1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 140.66, "gross_charge": 216.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23461", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24357-0701-06", "type": "NDC" } ], "description": "LIDOCAINE 4 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 GR", "billing_class": "facility", "discounted_cash": 1.69, "gross_charge": 2.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23490", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "13668-0011-01", "type": "NDC" } ], "description": "CITALOPRAM 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2350", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7100", "type": "HCPCS" }, { "code": "00409-7419-14", "type": "NDC" } ], "description": "DEXTRAN 40 10 % IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 202.96, "gross_charge": 312.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2357", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00338-0023-03", "type": "NDC" } ], "description": "DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 45.01, "gross_charge": 69.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2364", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7060", "type": "HCPCS" }, { "code": "00338-0017-02", "type": "NDC" } ], "description": "DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 42.96, "gross_charge": 66.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2365", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00409-6648-02", "type": "NDC" } ], "description": "DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 44.52, "gross_charge": 68.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2367", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0719-06", "type": "NDC" } ], "description": "DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2000 ML", "billing_class": "facility", "discounted_cash": 70.88, "gross_charge": 109.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23796", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1745", "type": "HCPCS" }, { "code": "57894-0030-01", "type": "NDC" } ], "description": "INFLIXIMAB 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3721.02, "gross_charge": 5724.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23814", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0245-14", "type": "NDC" } ], "description": "ATOVAQUONE 250 MG-PROGUANIL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.59, "gross_charge": 14.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23872", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "23155-0043-03", "type": "NDC" } ], "description": "LEFLUNOMIDE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.39, "gross_charge": 6.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23873", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0478-15", "type": "NDC" } ], "description": "LEFLUNOMIDE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.56, "gross_charge": 8.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-23968", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7519", "type": "HCPCS" }, { "code": "71288-0803-92", "type": "NDC" } ], "description": "MYCOPHENOLATE 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 76.02, "gross_charge": 116.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2403", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0286-20", "type": "NDC" } ], "description": "DIAZEPAM 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2404", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0284-20", "type": "NDC" } ], "description": "DIAZEPAM 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.49, "gross_charge": 8.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2405", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0285-20", "type": "NDC" } ], "description": "DIAZEPAM 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.49, "gross_charge": 8.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24119", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "65862-0057-24", "type": "NDC" } ], "description": "NEVIRAPINE 50 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 3.93, "gross_charge": 6.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2412", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1211-95", "type": "NDC" } ], "description": "DIBUCAINE 1 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 28 GR", "billing_class": "facility", "discounted_cash": 14.53, "gross_charge": 22.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2414", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-3123-01", "type": "NDC" } ], "description": "DICLOXACILLIN 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.06, "gross_charge": 6.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2417", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0500", "type": "HCPCS" }, { "code": "00517-1980-05", "type": "NDC" } ], "description": "DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 31.43, "gross_charge": 48.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24176", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0576-10", "type": "NDC" } ], "description": "MIDAZOLAM 2 MG/ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 16.54, "gross_charge": 25.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2418", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0369-01", "type": "NDC" } ], "description": "DICYCLOMINE 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24216", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0622-01", "type": "NDC" } ], "description": "SENNOSIDES 8.6 MG-DOCUSATE SODIUM 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24268", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0794-01", "type": "NDC" } ], "description": "ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24329", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "63323-0523-74", "type": "NDC" } ], "description": "HEPARIN (PORCINE) 25,000 UNIT/250 ML (100 UNIT/ML) IN DEXTROSE 5 % IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 60.0, "gross_charge": 92.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24385", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-3007-01", "type": "NDC" } ], "description": "HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 291.92, "gross_charge": 449.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24419", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3250-06", "type": "NDC" } ], "description": "LAMIVUDINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.02, "gross_charge": 38.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24425", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9357", "type": "HCPCS" }, { "code": "67979-0001-01", "type": "NDC" } ], "description": "VALRUBICIN 40 MG/ML INTRAVESICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 5092.49, "gross_charge": 7834.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24438", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0021-21", "type": "NDC" } ], "description": "ABACAVIR 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.73, "gross_charge": 18.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24439", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0405-24", "type": "NDC" } ], "description": "ABACAVIR 20 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 17.32, "gross_charge": 26.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2445", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-5922-61", "type": "NDC" } ], "description": "DIGOXIN 250 MCG (0.25 MG) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.84, "gross_charge": 7.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24474", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0177-15", "type": "NDC" } ], "description": "CILOSTAZOL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.32, "gross_charge": 6.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24500", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0436-01", "type": "NDC" } ], "description": "CELECOXIB 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.52, "gross_charge": 6.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24501", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0447-01", "type": "NDC" } ], "description": "CELECOXIB 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.26, "gross_charge": 8.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24513", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0885", "type": "HCPCS" }, { "code": "59676-0340-01", "type": "NDC" } ], "description": "EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 1851.04, "gross_charge": 2847.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24521", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0783-01", "type": "NDC" } ], "description": "ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24585", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7511", "type": "HCPCS" }, { "code": "58468-0080-01", "type": "NDC" } ], "description": "ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3688.78, "gross_charge": 5675.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24695", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0594", "type": "HCPCS" }, { "code": "16729-0351-92", "type": "NDC" } ], "description": "BUSULFAN 60 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 137.25, "gross_charge": 211.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24702", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0621-21", "type": "NDC" } ], "description": "MODAFINIL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.43, "gross_charge": 28.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24731", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-7040-12", "type": "NDC" } ], "description": "BELLADONNA ALKALOIDS-OPIUM 16.2 MG-60 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 68.18, "gross_charge": 104.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2475", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68682-0006-50", "type": "NDC" } ], "description": "DILTIAZEM 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2476", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68682-0007-10", "type": "NDC" } ], "description": "DILTIAZEM 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.06, "gross_charge": 6.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2477", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68682-0008-10", "type": "NDC" } ], "description": "DILTIAZEM 90 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.42, "gross_charge": 6.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24914", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7507", "type": "HCPCS" }, { "code": "51079-0817-20", "type": "NDC" } ], "description": "TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24916", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "76204-0900-11", "type": "NDC" } ], "description": "LEVALBUTEROL 1.25 MG/3 ML SOLUTION FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 6.01, "gross_charge": 9.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24932", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2916", "type": "HCPCS" }, { "code": "00143-9570-01", "type": "NDC" } ], "description": "SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 47.58, "gross_charge": 73.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-24984", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0505-55", "type": "NDC" } ], "description": "POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 238 GR", "billing_class": "facility", "discounted_cash": 18.56, "gross_charge": 28.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-250", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00487-9501-01", "type": "NDC" } ], "description": "ALBUTEROL SULFATE 2.5 MG/3 ML (0.083 %) SOLUTION FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25005", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7517", "type": "HCPCS" }, { "code": "66689-0307-08", "type": "NDC" } ], "description": "MYCOPHENOLATE MOFETIL 200 MG/ML ORAL POWDER FOR SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.25 ML", "billing_class": "facility", "discounted_cash": 7.8, "gross_charge": 12.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2505", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "68094-0018-61", "type": "NDC" } ], "description": "DIPHENHYDRAMINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2508", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1200", "type": "HCPCS" }, { "code": "00641-0376-25", "type": "NDC" } ], "description": "DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 21.71, "gross_charge": 33.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25118", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0076-01", "type": "NDC" } ], "description": "CIPROFLOXACIN 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25120", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59651-0873-50", "type": "NDC" } ], "description": "CIPROFLOXACIN 750 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2515", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-3194-46", "type": "NDC" } ], "description": "DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG/5 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 19.99, "gross_charge": 30.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2516", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0890-11", "type": "NDC" } ], "description": "DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.74, "gross_charge": 11.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2528", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00115-1070-01", "type": "NDC" } ], "description": "DIPYRIDAMOLE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2529", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0134-01", "type": "NDC" } ], "description": "DIPYRIDAMOLE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.6, "gross_charge": 10.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-253", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0949-25", "type": "NDC" } ], "description": "ALBUTEROL SULFATE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.58, "gross_charge": 19.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2536", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-3129-01", "type": "NDC" } ], "description": "DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.56, "gross_charge": 8.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25365", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0690", "type": "HCPCS" }, { "code": "00264-3103-11", "type": "NDC" } ], "description": "CEFAZOLIN 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 59.18, "gross_charge": 91.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2537", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00025-2732-31", "type": "NDC" } ], "description": "DISOPYRAMIDE PHOSPHATE ER 100 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.12, "gross_charge": 17.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25424", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0157-10", "type": "NDC" } ], "description": "POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.68, "gross_charge": 1.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2551", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62756-0796-88", "type": "NDC" } ], "description": "DIVALPROEX 125 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25519", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0270-11", "type": "NDC" } ], "description": "RISPERIDONE 0.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2552", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0473-03", "type": "NDC" } ], "description": "DIVALPROEX 250 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25520", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0271-01", "type": "NDC" } ], "description": "RISPERIDONE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25528", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0513-01", "type": "NDC" } ], "description": "PIOGLITAZONE 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.62, "gross_charge": 8.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25529", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0514-01", "type": "NDC" } ], "description": "PIOGLITAZONE 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.22, "gross_charge": 12.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2553", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0474-03", "type": "NDC" } ], "description": "DIVALPROEX 500 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2566", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0129-01", "type": "NDC" } ], "description": "DOCUSATE SODIUM 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2568", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "67618-0111-28", "type": "NDC" } ], "description": "DOCUSATE SODIUM 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.16, "gross_charge": 0.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-25820", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42799-0806-01", "type": "NDC" } ], "description": "IVERMECTIN 3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.5, "gross_charge": 16.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2595", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1265", "type": "HCPCS" }, { "code": "00409-5820-01", "type": "NDC" } ], "description": "DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 30.16, "gross_charge": 46.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2608", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0436-01", "type": "NDC" } ], "description": "DOXEPIN 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2611", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0437-01", "type": "NDC" } ], "description": "DOXEPIN 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.29, "gross_charge": 6.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2612", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0438-01", "type": "NDC" } ], "description": "DOXEPIN 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2614", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "54838-0512-40", "type": "NDC" } ], "description": "DOXEPIN 10 MG/ML ORAL CONCENTRATE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 8.26, "gross_charge": 12.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2622", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1271", "type": "HCPCS" }, { "code": "63323-0130-13", "type": "NDC" } ], "description": "DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 54.86, "gross_charge": 84.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26224", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0725-01", "type": "NDC" } ], "description": "PANTOPRAZOLE 20 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26225", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0736-01", "type": "NDC" } ], "description": "PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26226", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2470", "type": "HCPCS" }, { "code": "71288-0600-10", "type": "NDC" } ], "description": "PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.83, "gross_charge": 38.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2623", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0513-65", "type": "NDC" } ], "description": "DOXYCYCLINE HYCLATE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2625", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62584-0693-21", "type": "NDC" } ], "description": "DOXYCYCLINE HYCLATE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26371", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0923-01", "type": "NDC" } ], "description": "CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.22, "gross_charge": 6.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2654", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1790", "type": "HCPCS" }, { "code": "00143-9514-01", "type": "NDC" } ], "description": "DROPERIDOL 2.5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 24.12, "gross_charge": 37.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26546", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0677-11", "type": "NDC" } ], "description": "OSELTAMIVIR 75 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26547", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0188-21", "type": "NDC" } ], "description": "ENTACAPONE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.26, "gross_charge": 14.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26550", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70700-0163-01", "type": "NDC" } ], "description": "PROGESTERONE MICRONIZED 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.52, "gross_charge": 6.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26551", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59762-2858-01", "type": "NDC" } ], "description": "EXEMESTANE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.14, "gross_charge": 9.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26816", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0859-01", "type": "NDC" } ], "description": "LEVETIRACETAM 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26817", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0657-01", "type": "NDC" } ], "description": "LEVETIRACETAM 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-26966", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7523-08", "type": "NDC" } ], "description": "DOFETILIDE 250 MCG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.54, "gross_charge": 11.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27023", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24385-0524-03", "type": "NDC" } ], "description": "TERBINAFINE HCL 1 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 21.12, "gross_charge": 32.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27032", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" }, { "code": "64281-0100-00", "type": "NDC" } ], "description": "METHACHOLINE CHLORIDE 100 MG SOLUTION FOR INHALATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 173.91, "gross_charge": 267.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27103", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "55150-0209-02", "type": "NDC" } ], "description": "DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 27.27, "gross_charge": 41.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27181", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0584-11", "type": "NDC" } ], "description": "NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.2, "gross_charge": 8.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27182", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-7393-98", "type": "NDC" } ], "description": "NIACIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27234", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0573-11", "type": "NDC" } ], "description": "MONTELUKAST 4 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.29, "gross_charge": 6.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27327", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2260", "type": "HCPCS" }, { "code": "00143-9710-10", "type": "NDC" } ], "description": "MILRINONE 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 33.08, "gross_charge": 50.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27390", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "00641-6127-25", "type": "NDC" } ], "description": "MORPHINE 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 25.45, "gross_charge": 39.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27392", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2274", "type": "HCPCS" }, { "code": "00641-6040-01", "type": "NDC" } ], "description": "MORPHINE (PF) 25 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 1120.76, "gross_charge": 1724.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27430", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "23155-0748-31", "type": "NDC" } ], "description": "PENTAMIDINE 300 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 141.96, "gross_charge": 218.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27431", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q2050", "type": "HCPCS" }, { "code": "43598-0682-35", "type": "NDC" } ], "description": "DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 1181.02, "gross_charge": 1816.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27458", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-4643-16", "type": "NDC" } ], "description": "ESTRADIOL 0.0375 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 20.02, "gross_charge": 30.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27459", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-4642-26", "type": "NDC" } ], "description": "ESTRADIOL 0.05 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.92, "gross_charge": 29.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27461", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-4640-16", "type": "NDC" } ], "description": "ESTRADIOL 0.1 MG/24 HR SEMIWEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 19.11, "gross_charge": 29.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27466", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-0069-30", "type": "NDC" } ], "description": "DEXTROSE 40 % ORAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 38 GR", "billing_class": "facility", "discounted_cash": 1.92, "gross_charge": 2.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27467", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "55566-2800-01", "type": "NDC" } ], "description": "DINOPROSTONE ER 10 MG VAGINAL INSERT,CONTROLLED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1036.23, "gross_charge": 1594.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27471", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-9102-16", "type": "NDC" } ], "description": "NITROGLYCERIN 0.1 MG/HR TRANSDERMAL 24 HOUR PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.13, "gross_charge": 6.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27472", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-9104-93", "type": "NDC" } ], "description": "NITROGLYCERIN 0.2 MG/HR TRANSDERMAL 24 HOUR PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.06, "gross_charge": 6.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27474", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-9112-93", "type": "NDC" } ], "description": "NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.42, "gross_charge": 6.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27505", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "75907-0023-11", "type": "NDC" } ], "description": "CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.61, "gross_charge": 25.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27506", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "75907-0024-11", "type": "NDC" } ], "description": "CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.82, "gross_charge": 36.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27507", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00591-3510-04", "type": "NDC" } ], "description": "CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 119.24, "gross_charge": 183.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27631", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "27241-0115-10", "type": "NDC" } ], "description": "DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27634", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-6022-11", "type": "NDC" } ], "description": "CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.84, "gross_charge": 5.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27635", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0583-21", "type": "NDC" } ], "description": "CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.64, "gross_charge": 13.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27659", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0598-01", "type": "NDC" } ], "description": "NIFEDIPINE ER 60 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.73, "gross_charge": 10.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27660", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0599-15", "type": "NDC" } ], "description": "NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27663", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "83851-0100-30", "type": "NDC" } ], "description": "FLUORESCEIN 1 MG EYE STRIPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27666", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00283-0610-26", "type": "NDC" } ], "description": "BENZOCAINE 20 % MUCOSAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 GR", "billing_class": "facility", "discounted_cash": 0.62, "gross_charge": 0.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27696", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0580-62", "type": "NDC" } ], "description": "SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21.58, "gross_charge": 33.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27697", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0246-17", "type": "NDC" } ], "description": "ONDANSETRON 4 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27698", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0247-17", "type": "NDC" } ], "description": "ONDANSETRON 8 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27780", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0230-11", "type": "NDC" } ], "description": "ZONISAMIDE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.84, "gross_charge": 5.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27796", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00941-0409-05", "type": "NDC" } ], "description": "PERITON.DIALYSIS SOLN 6-1.5 % DEXTROS LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2000 ML", "billing_class": "facility", "discounted_cash": 103.8, "gross_charge": 159.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27800", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00941-0457-02", "type": "NDC" } ], "description": "PERITONEAL DIALYSIS SOLN 7-2.5 % DEXT.LOW CALC 2.5 MEQ/L-MAG 0.5 MEQ/L", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2000 ML", "billing_class": "facility", "discounted_cash": 103.8, "gross_charge": 159.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27804", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00941-0459-02", "type": "NDC" } ], "description": "PERITON. DIALYSIS SOLN 8-4.25 % DEXTROSE CALC 2.5 MEQ/L-MAG 0.5 MEQ/L", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2000 ML", "billing_class": "facility", "discounted_cash": 105.2, "gross_charge": 161.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27838", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7030", "type": "HCPCS" }, { "code": "00338-0049-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27857", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0698-01", "type": "NDC" } ], "description": "VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.8, "gross_charge": 5.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27858", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0709-01", "type": "NDC" } ], "description": "VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.84, "gross_charge": 5.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27859", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0713-01", "type": "NDC" } ], "description": "VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27860", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-5894-88", "type": "NDC" } ], "description": "NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.75, "gross_charge": 1.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27862", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-5895-88", "type": "NDC" } ], "description": "NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.75, "gross_charge": 1.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27863", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-5896-88", "type": "NDC" } ], "description": "NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.75, "gross_charge": 1.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27905", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0550-05", "type": "NDC" } ], "description": "FENTANYL 25 MCG/HR TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.88, "gross_charge": 27.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27906", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0552-05", "type": "NDC" } ], "description": "FENTANYL 50 MCG/HR TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 22.88, "gross_charge": 35.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27907", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0554-05", "type": "NDC" } ], "description": "FENTANYL 75 MCG/HR TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 30.42, "gross_charge": 46.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27908", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0556-05", "type": "NDC" } ], "description": "FENTANYL 100 MCG/HR TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 37.93, "gross_charge": 58.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27913", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-9202-30", "type": "NDC" } ], "description": "FENTANYL 200 MCG LOZENGE ON A HANDLE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21.29, "gross_charge": 32.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27927", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-1133-03", "type": "NDC" } ], "description": "AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 56.06, "gross_charge": 86.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27927", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-1089-04", "type": "NDC" } ], "description": "AMINO ACID 4.25 % NO.1 IN DEXTROSE 5 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2000 ML", "billing_class": "facility", "discounted_cash": 96.88, "gross_charge": 149.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27963", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-1123-04", "type": "NDC" } ], "description": "AMINO ACID 5 % NO.6-DEXTROSE 15 %-ELECTROLYTES NO.23 IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2000 ML", "billing_class": "facility", "discounted_cash": 233.64, "gross_charge": 359.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27980", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00065-0408-72", "type": "NDC" } ], "description": "ARTIFICIAL TEARS (HYPROMELLOSE) 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 75.66, "gross_charge": 116.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-27994", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0678-15", "type": "NDC" } ], "description": "POLYVINYL ALCOHOL 1.4 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 26.06, "gross_charge": 40.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28011", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0409-06", "type": "NDC" } ], "description": "SERTRALINE 20 MG/ML ORAL CONCENTRATE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.25 ML", "billing_class": "facility", "discounted_cash": 4.74, "gross_charge": 7.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28055", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-2533-21", "type": "NDC" } ], "description": "CALAMINE 8 %-ZINC OXIDE 8 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 177 ML", "billing_class": "facility", "discounted_cash": 0.94, "gross_charge": 1.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28112", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "65219-0387-02", "type": "NDC" } ], "description": "ELECTROLYTE-148 INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 70.88, "gross_charge": 109.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28113", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0221-04", "type": "NDC" } ], "description": "ELECTROLYTE-A INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28158", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0529-01", "type": "NDC" } ], "description": "OLANZAPINE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28159", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64380-0172-02", "type": "NDC" } ], "description": "OLANZAPINE 5 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.62, "gross_charge": 7.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28224", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0309-21", "type": "NDC" } ], "description": "LINEZOLID 600 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.02, "gross_charge": 10.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28225", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0754-05", "type": "NDC" } ], "description": "LINEZOLID 100 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 150 ML", "billing_class": "facility", "discounted_cash": 516.68, "gross_charge": 794.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28228", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0564-24", "type": "NDC" } ], "description": "CITALOPRAM 10 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 5.3, "gross_charge": 8.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28235", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0877-15", "type": "NDC" } ], "description": "PENTAMIDINE 300 MG SOLUTION FOR INHALATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 184.92, "gross_charge": 284.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28252", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0313-15", "type": "NDC" } ], "description": "FENOFIBRATE 160 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.46, "gross_charge": 8.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28278", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0777-01", "type": "NDC" } ], "description": "RIVASTIGMINE 1.5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.34, "gross_charge": 11.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28282", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J1815", "type": "HCPCS" }, { "code": "00088-2220-33", "type": "NDC" } ], "description": "INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 202.28, "gross_charge": 311.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28351", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70069-0091-01", "type": "NDC" } ], "description": "AZELASTINE 0.05 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 20.02, "gross_charge": 30.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28372", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0385-25", "type": "NDC" } ], "description": "COLESEVELAM 625 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.35, "gross_charge": 12.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28384", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0418-01", "type": "NDC" } ], "description": "HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.63, "gross_charge": 10.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28400", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0013-04", "type": "NDC" } ], "description": "WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.38, "gross_charge": 71.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28409", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-3352-16", "type": "NDC" } ], "description": "ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 35.78, "gross_charge": 55.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2848", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0168", "type": "HCPCS" }, { "code": "76329-3318-01", "type": "NDC" } ], "description": "EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 31.78, "gross_charge": 48.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28530", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3101", "type": "HCPCS" }, { "code": "00000-0015-70", "type": "NDC" } ], "description": "TENECTEPLASE 50 MG INTRAVENOUS KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 1233.38, "gross_charge": 1897.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2863", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0297-15", "type": "NDC" } ], "description": "ERGOCALCIFEROL (VITAMIN D2) 1,250 MCG (50,000 UNIT) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.62, "gross_charge": 7.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28645", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0590-25", "type": "NDC" } ], "description": "ATORVASTATIN 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.8, "gross_charge": 5.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28774", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00487-9601-01", "type": "NDC" } ], "description": "BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 14.95, "gross_charge": 23.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28775", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0524-83", "type": "NDC" } ], "description": "BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 9.75, "gross_charge": 15.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28810", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0448-01", "type": "NDC" } ], "description": "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG-10,000 UNIT/ML-1 % EAR DROPS,SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 200.46, "gross_charge": 308.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28824", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0431-30", "type": "NDC" } ], "description": "HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 28.57, "gross_charge": 43.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28829", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00395-1667-92", "type": "NDC" } ], "description": "METHYL SALICYLATE TOPICAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 59 ML", "billing_class": "facility", "discounted_cash": 22.49, "gross_charge": 34.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28842", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7515", "type": "HCPCS" }, { "code": "00093-9018-19", "type": "NDC" } ], "description": "CYCLOSPORINE MODIFIED 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.84, "gross_charge": 5.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28843", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7502", "type": "HCPCS" }, { "code": "00093-9020-65", "type": "NDC" } ], "description": "CYCLOSPORINE MODIFIED 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.47, "gross_charge": 9.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28844", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7502", "type": "HCPCS" }, { "code": "00078-0274-22", "type": "NDC" } ], "description": "CYCLOSPORINE MODIFIED 100 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 1206.6, "gross_charge": 1856.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2888", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-4024-35", "type": "NDC" } ], "description": "ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 GR", "billing_class": "facility", "discounted_cash": 38.68, "gross_charge": 59.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28899", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0975-01", "type": "NDC" } ], "description": "OXYCODONE 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.28, "gross_charge": 11.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28900", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0185-11", "type": "NDC" } ], "description": "OXYCODONE 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.33, "gross_charge": 8.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28911", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9050", "type": "HCPCS" }, { "code": "54879-0036-64", "type": "NDC" } ], "description": "CARMUSTINE 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1000.58, "gross_charge": 1539.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28912", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9120", "type": "HCPCS" }, { "code": "55292-0811-55", "type": "NDC" } ], "description": "DACTINOMYCIN 0.5 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7356.31, "gross_charge": 11317.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28947", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0883", "type": "HCPCS" }, { "code": "42023-0182-01", "type": "NDC" } ], "description": "ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 383.14, "gross_charge": 589.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28958", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7520", "type": "HCPCS" }, { "code": "68084-0915-25", "type": "NDC" } ], "description": "SIROLIMUS 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.02, "gross_charge": 24.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28964", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6353-61", "type": "NDC" } ], "description": "LEVOFLOXACIN 750 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2899", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0630-01", "type": "NDC" } ], "description": "ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL POWDER FOR SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 17.62, "gross_charge": 27.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-28995", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70010-0491-05", "type": "NDC" } ], "description": "METFORMIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.06, "gross_charge": 4.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2900", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0631-01", "type": "NDC" } ], "description": "ERYTHROMYCIN ETHYLSUCCINATE 400 MG/5 ML ORAL POWDER FOR SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 37.31, "gross_charge": 57.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2901", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "80005-0161-08", "type": "NDC" } ], "description": "ERYTHROMYCIN ETHYLSUCCINATE 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.87, "gross_charge": 39.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2903", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1364", "type": "HCPCS" }, { "code": "00409-6482-01", "type": "NDC" } ], "description": "ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 205.82, "gross_charge": 316.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29071", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9017", "type": "HCPCS" }, { "code": "70121-1483-07", "type": "NDC" } ], "description": "ARSENIC TRIOXIDE 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 148.23, "gross_charge": 228.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29132", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1756", "type": "HCPCS" }, { "code": "00517-2340-10", "type": "NDC" } ], "description": "IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 128.44, "gross_charge": 197.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29169", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00071-2012-06", "type": "NDC" } ], "description": "GABAPENTIN 250 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 21.61, "gross_charge": 33.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29267", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0371-01", "type": "NDC" } ], "description": "QUETIAPINE 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29270", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0195-01", "type": "NDC" } ], "description": "DILTIAZEM CD 120 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29272", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0206-01", "type": "NDC" } ], "description": "DILTIAZEM CD 180 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29274", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7219-61", "type": "NDC" } ], "description": "DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29280", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7298", "type": "HCPCS" }, { "code": "50419-0423-01", "type": "NDC" } ], "description": "LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2211.85, "gross_charge": 3402.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29287", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0681-07", "type": "NDC" } ], "description": "DOCOSANOL 10 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 GR", "billing_class": "facility", "discounted_cash": 6.37, "gross_charge": 9.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2929", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1000", "type": "HCPCS" }, { "code": "00009-0271-01", "type": "NDC" } ], "description": "ESTRADIOL CYPIONATE 5 MG/ML INTRAMUSCULAR OIL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 50.99, "gross_charge": 78.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29299", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-2575-07", "type": "NDC" } ], "description": "BALSALAZIDE 750 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.36, "gross_charge": 6.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2931", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1380", "type": "HCPCS" }, { "code": "42023-0111-01", "type": "NDC" } ], "description": "ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 77.8, "gross_charge": 119.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29313", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0840", "type": "HCPCS" }, { "code": "50633-0110-12", "type": "NDC" } ], "description": "CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9659.46, "gross_charge": 14860.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29335", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1800", "type": "HCPCS" }, { "code": "00143-9872-01", "type": "NDC" } ], "description": "PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 35.88, "gross_charge": 55.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2938", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00046-1104-81", "type": "NDC" } ], "description": "CONJUGATED ESTROGENS 1.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.28, "gross_charge": 25.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29396", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0583", "type": "HCPCS" }, { "code": "71288-0427-92", "type": "NDC" } ], "description": "BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 139.49, "gross_charge": 214.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29424", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00168-0258-15", "type": "NDC" } ], "description": "CLOTRIMAZOLE-BETAMETHASONE 1 %-0.05 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 47.0, "gross_charge": 72.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29434", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-7163-56", "type": "NDC" } ], "description": "TOLTERODINE ER 2 MG CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.08, "gross_charge": 23.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29437", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0673-21", "type": "NDC" } ], "description": "NATEGLINIDE 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.18, "gross_charge": 9.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29464", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "00641-6020-01", "type": "NDC" } ], "description": "MORPHINE (PF) 0.5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 30.55, "gross_charge": 47.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-2951", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00386-0001-13", "type": "NDC" } ], "description": "ETHYL CHLORIDE 100 % TOPICAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 105 ML", "billing_class": "facility", "discounted_cash": 80.24, "gross_charge": 123.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29531", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57237-0011-06", "type": "NDC" } ], "description": "MIRTAZAPINE 15 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29676", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-3865-75", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 44 ML", "billing_class": "facility", "discounted_cash": 7.9, "gross_charge": 12.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29778", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0103-11", "type": "NDC" } ], "description": "ZIPRASIDONE 20 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.6, "gross_charge": 10.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29779", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0104-09", "type": "NDC" } ], "description": "ZIPRASIDONE 40 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.63, "gross_charge": 10.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29805", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1805", "type": "HCPCS" }, { "code": "10019-0672-10", "type": "NDC" } ], "description": "ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 260.16, "gross_charge": 400.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29806", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0729-21", "type": "NDC" } ], "description": "GALANTAMINE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.88, "gross_charge": 15.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29807", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0459-60", "type": "NDC" } ], "description": "GALANTAMINE 8 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.26, "gross_charge": 6.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29822", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42192-0338-01", "type": "NDC" } ], "description": "HYOSCYAMINE 0.125 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-29833", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60258-0160-01", "type": "NDC" } ], "description": "VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30070", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0402-01", "type": "NDC" } ], "description": "METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30071", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0413-01", "type": "NDC" } ], "description": "METOPROLOL SUCCINATE ER 100 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.93, "gross_charge": 6.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30148", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0965-25", "type": "NDC" } ], "description": "VALGANCICLOVIR 450 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21.68, "gross_charge": 33.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3037", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00409-9094-22", "type": "NDC" } ], "description": "FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 23.63, "gross_charge": 36.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30479", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0687-25", "type": "NDC" } ], "description": "OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 4.71, "gross_charge": 7.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30538", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43900-0976-47", "type": "NDC" } ], "description": "GUAR GUM ORAL PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.61, "gross_charge": 39.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30594", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2272", "type": "HCPCS" }, { "code": "63323-0452-01", "type": "NDC" } ], "description": "MORPHINE 2 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 26.94, "gross_charge": 41.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30699", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0257-01", "type": "NDC" } ], "description": "ROPINIROLE 3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3071", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "58526-0005-57", "type": "NDC" } ], "description": "FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3074", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7591-61", "type": "NDC" } ], "description": "FERROUS SULFATE 325 MG (65 MG IRON) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30807", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "63037-0101-05", "type": "NDC" } ], "description": "FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 157.95, "gross_charge": 243.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-30961", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7119-06", "type": "NDC" } ], "description": "CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.42, "gross_charge": 6.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-310", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0677-01", "type": "NDC" } ], "description": "ALLOPURINOL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31025", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9267", "type": "HCPCS" }, { "code": "70860-0200-50", "type": "NDC" } ], "description": "PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 178.62, "gross_charge": 274.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-311", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0688-11", "type": "NDC" } ], "description": "ALLOPURINOL 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31158", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0144-05", "type": "NDC" } ], "description": "BRIMONIDINE 0.15 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 389.87, "gross_charge": 599.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31209", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "67877-0416-90", "type": "NDC" } ], "description": "VALSARTAN 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31210", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "55111-0733-90", "type": "NDC" } ], "description": "VALSARTAN 160 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31270", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q9957", "type": "HCPCS" }, { "code": "11994-0011-01", "type": "NDC" } ], "description": "PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 489.38, "gross_charge": 752.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31288", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "53746-0617-01", "type": "NDC" } ], "description": "TRAMADOL 37.5 MG-ACETAMINOPHEN 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.75, "gross_charge": 8.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31310", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "00000-0107-04", "type": "NDC" } ], "description": "ALTEPLASE 2 MG INTRA-CATHETER SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 452.56, "gross_charge": 696.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31432", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1162", "type": "HCPCS" }, { "code": "50633-0120-11", "type": "NDC" } ], "description": "DIGOXIN IMMUNE FAB 40 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15014.28, "gross_charge": 23098.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31576", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0596-32", "type": "NDC" } ], "description": "BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.69, "gross_charge": 28.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31588", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "35573-0467-02", "type": "NDC" } ], "description": "DEXTROAMPHETAMINE-AMPHETAMINE ER 20 MG 24HR CAPSULE,EXTEND RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.09, "gross_charge": 12.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31684", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0758-11", "type": "NDC" } ], "description": "TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.11, "gross_charge": 9.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31784", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "66658-0234-07", "type": "NDC" } ], "description": "ANAKINRA 100 MG/0.67 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.67 ML", "billing_class": "facility", "discounted_cash": 704.7, "gross_charge": 1084.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31863", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0699-01", "type": "NDC" } ], "description": "OXYCODONE-ACETAMINOPHEN 7.5 MG-325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.45, "gross_charge": 13.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31864", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0710-11", "type": "NDC" } ], "description": "OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.35, "gross_charge": 12.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3187", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-0262-30", "type": "NDC" } ], "description": "FLUOCINONIDE 0.05 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 45.14, "gross_charge": 69.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3189", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-1264-01", "type": "NDC" } ], "description": "FLUOCINONIDE 0.05 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 37.44, "gross_charge": 57.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3190", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "33342-0320-84", "type": "NDC" } ], "description": "FLUOCINONIDE 0.05 % TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 49.46, "gross_charge": 76.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31921", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00781-3299-69", "type": "NDC" } ], "description": "ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 57.59, "gross_charge": 88.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-31922", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1335", "type": "HCPCS" }, { "code": "55150-0282-09", "type": "NDC" } ], "description": "ERTAPENEM 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 99.0, "gross_charge": 152.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3215", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2680", "type": "HCPCS" }, { "code": "55150-0267-05", "type": "NDC" } ], "description": "FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 33.48, "gross_charge": 51.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3216", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2679", "type": "HCPCS" }, { "code": "63323-0281-10", "type": "NDC" } ], "description": "FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 37.93, "gross_charge": 58.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3218", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00527-1788-01", "type": "NDC" } ], "description": "FLUPHENAZINE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3220", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0367-15", "type": "NDC" } ], "description": "FLUPHENAZINE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.77, "gross_charge": 11.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3221", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0749-01", "type": "NDC" } ], "description": "FLUPHENAZINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.84, "gross_charge": 13.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32215", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1652", "type": "HCPCS" }, { "code": "55150-0230-10", "type": "NDC" } ], "description": "FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 41.21, "gross_charge": 63.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32267", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2506", "type": "HCPCS" }, { "code": "55513-0190-01", "type": "NDC" } ], "description": "PEGFILGRASTIM 6 MG/0.6 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 10005.45, "gross_charge": 15393.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32298", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0504-30", "type": "NDC" } ], "description": "EFAVIRENZ 600 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.03, "gross_charge": 12.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3232", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1808", "type": "HCPCS" }, { "code": "39822-1100-01", "type": "NDC" } ], "description": "FOLIC ACID 5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 23.2, "gross_charge": 35.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3233", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0681-01", "type": "NDC" } ], "description": "FOLIC ACID 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-324", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0377-11", "type": "NDC" } ], "description": "ALPRAZOLAM 0.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.92, "gross_charge": 9.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32415", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-8960-01", "type": "NDC" } ], "description": "DEXTROAMPHETAMINE SULFATE ER 5 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.94, "gross_charge": 13.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32416", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-8961-01", "type": "NDC" } ], "description": "DEXTROAMPHETAMINE SULFATE ER 10 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.94, "gross_charge": 15.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32569", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63256-0100-30", "type": "NDC" } ], "description": "STERILE TALC 4 GRAM INTRAPLEURAL AEROSOL POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 GR", "billing_class": "facility", "discounted_cash": 339.24, "gross_charge": 521.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32589", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2430", "type": "HCPCS" }, { "code": "61703-0324-18", "type": "NDC" } ], "description": "PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 64.77, "gross_charge": 99.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-326", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0678-01", "type": "NDC" } ], "description": "ALPRAZOLAM 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.43, "gross_charge": 8.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32700", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0585", "type": "HCPCS" }, { "code": "00023-1145-01", "type": "NDC" } ], "description": "ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2154.07, "gross_charge": 3313.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32855", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2430", "type": "HCPCS" }, { "code": "67457-0446-10", "type": "NDC" } ], "description": "PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 105.98, "gross_charge": 163.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32893", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" }, { "code": "62935-0753-75", "type": "NDC" } ], "description": "LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 296.95, "gross_charge": 456.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3291", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1938", "type": "HCPCS" }, { "code": "00409-6102-27", "type": "NDC" } ], "description": "FUROSEMIDE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 24.41, "gross_charge": 37.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3291", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1938", "type": "HCPCS" }, { "code": "63323-0280-02", "type": "NDC" } ], "description": "FUROSEMIDE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 27.69, "gross_charge": 42.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3291", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1938", "type": "HCPCS" }, { "code": "00409-6102-26", "type": "NDC" } ], "description": "FUROSEMIDE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 25.84, "gross_charge": 39.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3293", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68094-0867-59", "type": "NDC" } ], "description": "FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.66, "gross_charge": 10.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32931", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3285", "type": "HCPCS" }, { "code": "66302-0101-01", "type": "NDC" } ], "description": "TREPROSTINIL SODIUM 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 4280.18, "gross_charge": 6584.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3294", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43547-0401-10", "type": "NDC" } ], "description": "FUROSEMIDE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3295", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69315-0117-10", "type": "NDC" } ], "description": "FUROSEMIDE 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-32950", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2260", "type": "HCPCS" }, { "code": "00143-9719-01", "type": "NDC" } ], "description": "MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 50.18, "gross_charge": 77.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3296", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-8301-25", "type": "NDC" } ], "description": "FUROSEMIDE 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33010", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3465", "type": "HCPCS" }, { "code": "00049-3190-01", "type": "NDC" } ], "description": "VORICONAZOLE 200 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 64.77, "gross_charge": 99.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33083", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0409-25", "type": "NDC" } ], "description": "MIDODRINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.45, "gross_charge": 6.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33175", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3486", "type": "HCPCS" }, { "code": "43598-0848-58", "type": "NDC" } ], "description": "ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 63.6, "gross_charge": 97.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33227", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0502-20", "type": "NDC" } ], "description": "AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33228", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0503-01", "type": "NDC" } ], "description": "AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33230", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0534-01", "type": "NDC" } ], "description": "AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33512", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0617-01", "type": "NDC" } ], "description": "ESCITALOPRAM 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33541", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0612-21", "type": "NDC" } ], "description": "VALSARTAN 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.32, "gross_charge": 6.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33591", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2783", "type": "HCPCS" }, { "code": "00024-5150-10", "type": "NDC" } ], "description": "RASBURICASE 1.5 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3038.1, "gross_charge": 4674.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3378", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0224-01", "type": "NDC" } ], "description": "GEMFIBROZIL 600 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-33963", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0663-11", "type": "NDC" } ], "description": "METAXALONE 800 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.34, "gross_charge": 15.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34034", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "82154-0449-01", "type": "NDC" } ], "description": "PEGINTERFERON ALFA-2A 180 MCG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.75 ML", "billing_class": "facility", "discounted_cash": 2538.51, "gross_charge": 3905.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34153", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0373-21", "type": "NDC" } ], "description": "EZETIMIBE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.86, "gross_charge": 18.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3423", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0056-35", "type": "NDC" } ], "description": "GENTAMICIN 0.1 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 104.58, "gross_charge": 160.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3424", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00713-0682-15", "type": "NDC" } ], "description": "GENTAMICIN 0.1 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 45.6, "gross_charge": 70.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3426", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1580", "type": "HCPCS" }, { "code": "63323-0010-20", "type": "NDC" } ], "description": "GENTAMICIN 40 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 96.62, "gross_charge": 148.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3428", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0633-05", "type": "NDC" } ], "description": "GENTAMICIN 0.3 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 15.4, "gross_charge": 23.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3430", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00395-1003-92", "type": "NDC" } ], "description": "GENTIAN VIOLET 1 % TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 59 ML", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34369", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0179-01", "type": "NDC" } ], "description": "ARIPIPRAZOLE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34370", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0191-21", "type": "NDC" } ], "description": "ARIPIPRAZOLE 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.33, "gross_charge": 8.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34418", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0594-01", "type": "NDC" } ], "description": "DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34444", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0373-03", "type": "NDC" } ], "description": "ATOMOXETINE 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.08, "gross_charge": 9.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34445", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0374-03", "type": "NDC" } ], "description": "ATOMOXETINE 18 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.08, "gross_charge": 9.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34447", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64980-0376-03", "type": "NDC" } ], "description": "ATOMOXETINE 40 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.34, "gross_charge": 9.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34448", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "55111-0522-30", "type": "NDC" } ], "description": "ATOMOXETINE 60 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.3, "gross_charge": 8.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34505", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0396-11", "type": "NDC" } ], "description": "HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.24, "gross_charge": 9.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34524", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2543", "type": "HCPCS" }, { "code": "00338-9636-01", "type": "NDC" } ], "description": "PIPERACILLIN-TAZOBACTAM 3.375 GRAM/50 ML DEXTROSE(ISO-OS) IV PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 93.5, "gross_charge": 143.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34544", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0407-01", "type": "NDC" } ], "description": "HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.4, "gross_charge": 9.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34711", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0571", "type": "HCPCS" }, { "code": "60687-0481-21", "type": "NDC" } ], "description": "BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.85, "gross_charge": 15.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34712", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0571", "type": "HCPCS" }, { "code": "60687-0492-21", "type": "NDC" } ], "description": "BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 13.06, "gross_charge": 20.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34713", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0572", "type": "HCPCS" }, { "code": "50268-0144-11", "type": "NDC" } ], "description": "BUPRENORPHINE 2 MG-NALOXONE 0.5 MG SUBLINGUAL TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.49, "gross_charge": 14.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34714", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J0574", "type": "HCPCS" }, { "code": "50268-0145-11", "type": "NDC" } ], "description": "BUPRENORPHINE 8 MG-NALOXONE 2 MG SUBLINGUAL TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.5, "gross_charge": 16.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34770", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0255-16", "type": "NDC" } ], "description": "NICOTINE (POLACRILEX) 4 MG BUCCAL LOZENGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.2, "gross_charge": 0.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-34814", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0631-10", "type": "NDC" } ], "description": "NEOMYCIN-POLYMYXIN-HYDROCORT 3.5 MG/ML-10,000 UNIT/ML-1 % EAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 149.5, "gross_charge": 230.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35126", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0641-75", "type": "NDC" } ], "description": "NEOMYCIN 3.5 MG-POLYMYXIN 10,000 UNIT-HYDROCORT 10 MG/ML EYE DROP,SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7.5 ML", "billing_class": "facility", "discounted_cash": 380.7, "gross_charge": 585.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35134", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0245-11", "type": "NDC" } ], "description": "ROSUVASTATIN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.74, "gross_charge": 7.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35135", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0256-11", "type": "NDC" } ], "description": "ROSUVASTATIN 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.07, "gross_charge": 7.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35184", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0753-25", "type": "NDC" } ], "description": "CYCLOBENZAPRINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35236", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" }, { "code": "62935-0303-30", "type": "NDC" } ], "description": "LEUPROLIDE 30 MG (4 MONTH) SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1027.62, "gross_charge": 1580.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3542", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1744-00", "type": "NDC" } ], "description": "GUAIFENESIN 100 MG/5 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 1.92, "gross_charge": 2.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35640", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3489", "type": "HCPCS" }, { "code": "43598-0330-11", "type": "NDC" } ], "description": "ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 39.84, "gross_charge": 61.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35686", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59746-0010-32", "type": "NDC" } ], "description": "RISPERIDONE 0.5 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.69, "gross_charge": 8.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35687", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49884-0315-55", "type": "NDC" } ], "description": "RISPERIDONE 1 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.69, "gross_charge": 16.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35688", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59746-0030-22", "type": "NDC" } ], "description": "RISPERIDONE 2 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.42, "gross_charge": 12.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35699", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0582-04", "type": "NDC" } ], "description": "MOXIFLOXACIN 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 173.36, "gross_charge": 266.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35771", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0551-15", "type": "NDC" } ], "description": "METFORMIN ER 750 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35775", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0180", "type": "HCPCS" }, { "code": "58468-0040-01", "type": "NDC" } ], "description": "AGALSIDASE BETA 35 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25664.18, "gross_charge": 39483.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3578", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0733-20", "type": "NDC" } ], "description": "HALOPERIDOL 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3579", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0734-20", "type": "NDC" } ], "description": "HALOPERIDOL 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3580", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0249-11", "type": "NDC" } ], "description": "HALOPERIDOL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.55, "gross_charge": 7.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3581", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0735-20", "type": "NDC" } ], "description": "HALOPERIDOL 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.06, "gross_charge": 6.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3583", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6782-61", "type": "NDC" } ], "description": "HALOPERIDOL 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.03, "gross_charge": 6.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35839", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9041", "type": "HCPCS" }, { "code": "25021-0262-10", "type": "NDC" } ], "description": "BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 80.92, "gross_charge": 124.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3584", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1630", "type": "HCPCS" }, { "code": "67457-0426-12", "type": "NDC" } ], "description": "HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 22.07, "gross_charge": 33.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3585", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-0581-05", "type": "NDC" } ], "description": "HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-35942", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0632-11", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE(PART/CRYST)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36046", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0704-34", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.38, "gross_charge": 71.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36092", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59651-0241-30", "type": "NDC" } ], "description": "IMATINIB 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.15, "gross_charge": 11.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36135", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-5613-01", "type": "NDC" } ], "description": "CARBIDOPA 12.5 MG-LEVODOPA 50 MG-ENTACAPONE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.58, "gross_charge": 7.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36136", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-5637-01", "type": "NDC" } ], "description": "CARBIDOPA 25 MG-LEVODOPA 100 MG-ENTACAPONE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.58, "gross_charge": 7.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36150", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42385-0921-60", "type": "NDC" } ], "description": "ATAZANAVIR 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.16, "gross_charge": 12.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36151", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2357", "type": "HCPCS" }, { "code": "50242-0040-62", "type": "NDC" } ], "description": "OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4797.94, "gross_charge": 7381.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36198", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00046-1101-81", "type": "NDC" } ], "description": "CONJUGATED ESTROGENS 0.45 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.28, "gross_charge": 25.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36252", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61958-0601-01", "type": "NDC" } ], "description": "EMTRICITABINE 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 36.6, "gross_charge": 56.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-364", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0422-01", "type": "NDC" } ], "description": "AMANTADINE HCL 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.74, "gross_charge": 7.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36438", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0168-01", "type": "NDC" } ], "description": "ARIPIPRAZOLE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-365", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0797-56", "type": "NDC" } ], "description": "AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.04, "gross_charge": 9.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36576", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-6186-67", "type": "NDC" } ], "description": "CIPROFLOXACIN 0.3 %-DEXAMETHASONE 0.1 % EAR DROPS,SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7.5 ML", "billing_class": "facility", "discounted_cash": 204.49, "gross_charge": 314.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36591", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2469", "type": "HCPCS" }, { "code": "00781-3415-75", "type": "NDC" } ], "description": "PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 66.66, "gross_charge": 102.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36775", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0782-01", "type": "NDC" } ], "description": "BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.43, "gross_charge": 8.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36959", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51862-0240-30", "type": "NDC" } ], "description": "AMIODARONE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.26, "gross_charge": 12.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36962", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1870-00", "type": "NDC" } ], "description": "DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 4.74, "gross_charge": 7.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36966", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0184-57", "type": "NDC" } ], "description": "MEMANTINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3697", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0360", "type": "HCPCS" }, { "code": "63323-0614-55", "type": "NDC" } ], "description": "HYDRALAZINE 20 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 31.62, "gross_charge": 48.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3698", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0811-01", "type": "NDC" } ], "description": "HYDRALAZINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36983", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0451-21", "type": "NDC" } ], "description": "EPLERENONE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.45, "gross_charge": 13.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36987", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0242-00", "type": "NDC" } ], "description": "ZONISAMIDE 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36988", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0243-00", "type": "NDC" } ], "description": "ZONISAMIDE 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-36989", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0878", "type": "HCPCS" }, { "code": "71288-0016-15", "type": "NDC" } ], "description": "DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 69.65, "gross_charge": 107.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3700", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0520-01", "type": "NDC" } ], "description": "HYDRALAZINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3701", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0833-01", "type": "NDC" } ], "description": "HYDRALAZINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37170", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0173-57", "type": "NDC" } ], "description": "MEMANTINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3720", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0593-01", "type": "NDC" } ], "description": "HYDROCHLOROTHIAZIDE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37237", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2794", "type": "HCPCS" }, { "code": "50458-0306-11", "type": "NDC" } ], "description": "RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1927.58, "gross_charge": 2965.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37238", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2794", "type": "HCPCS" }, { "code": "50458-0307-11", "type": "NDC" } ], "description": "RISPERIDONE MICROSPHERES ER 37.5 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEAS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2880.77, "gross_charge": 4431.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37239", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2794", "type": "HCPCS" }, { "code": "50458-0308-11", "type": "NDC" } ], "description": "RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3834.02, "gross_charge": 5898.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3726", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24385-0021-03", "type": "NDC" } ], "description": "HYDROCORTISONE 1 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 0.65, "gross_charge": 1.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3728", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00394-0859-32", "type": "NDC" } ], "description": "HYDROCORTISONE 1 % LOTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 120 ML", "billing_class": "facility", "discounted_cash": 4.39, "gross_charge": 6.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3733", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0582-01", "type": "NDC" } ], "description": "HYDROCORTISONE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3734", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0407-15", "type": "NDC" } ], "description": "HYDROCORTISONE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3738", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0411-24", "type": "NDC" } ], "description": "HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37400", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43598-0575-30", "type": "NDC" } ], "description": "TADALAFIL 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3757", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "76045-0009-11", "type": "NDC" } ], "description": "HYDROMORPHONE (PF) 1 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 29.74, "gross_charge": 45.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3760", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42858-0301-25", "type": "NDC" } ], "description": "HYDROMORPHONE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.75, "gross_charge": 8.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3761", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0590-01", "type": "NDC" } ], "description": "HYDROMORPHONE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.27, "gross_charge": 9.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37635", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43547-0280-10", "type": "NDC" } ], "description": "ESCITALOPRAM 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62584-0265-01", "type": "NDC" } ], "description": "METOPROLOL TARTRATE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37642", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0596-02", "type": "NDC" } ], "description": "CLINDAMYCIN 75 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 4.71, "gross_charge": 7.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37645", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-0742-60", "type": "NDC" } ], "description": "PROPAFENONE ER 425 MG CAPSULE,EXTENDED RELEASE 12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37665", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-5504-56", "type": "NDC" } ], "description": "OLANZAPINE-FLUOXETINE 6 MG-25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.18, "gross_charge": 23.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37666", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-5505-56", "type": "NDC" } ], "description": "OLANZAPINE-FLUOXETINE 6 MG-50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 13.98, "gross_charge": 21.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37667", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-5506-56", "type": "NDC" } ], "description": "OLANZAPINE-FLUOXETINE 12 MG-25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.98, "gross_charge": 29.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3769", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3410", "type": "HCPCS" }, { "code": "00517-4201-25", "type": "NDC" } ], "description": "HYDROXYZINE HCL 25 MG/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 80.11, "gross_charge": 123.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3770", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3410", "type": "HCPCS" }, { "code": "00517-5601-25", "type": "NDC" } ], "description": "HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 55.8, "gross_charge": 85.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3771", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "54838-0502-80", "type": "NDC" } ], "description": "HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 152.65, "gross_charge": 234.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3772", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0664-11", "type": "NDC" } ], "description": "HYDROXYZINE HCL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37812", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63256-0200-05", "type": "NDC" } ], "description": "STERILE TALC 5 GRAM INTRAPLEURAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 308.04, "gross_charge": 473.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37848", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1544-40", "type": "NDC" } ], "description": "HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 28.83, "gross_charge": 44.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37894", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9305", "type": "HCPCS" }, { "code": "71288-0167-95", "type": "NDC" } ], "description": "PEMETREXED DISODIUM 500 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 180.15, "gross_charge": 277.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-37989", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9055", "type": "HCPCS" }, { "code": "66733-0948-23", "type": "NDC" } ], "description": "CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 2257.48, "gross_charge": 3473.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38062", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7518", "type": "HCPCS" }, { "code": "00078-0385-66", "type": "NDC" } ], "description": "MYCOPHENOLATE SODIUM 180 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.74, "gross_charge": 27.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38063", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7518", "type": "HCPCS" }, { "code": "68084-0918-25", "type": "NDC" } ], "description": "MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 15.14, "gross_charge": 23.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38072", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2791", "type": "HCPCS" }, { "code": "44206-0300-01", "type": "NDC" } ], "description": "RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 232.21, "gross_charge": 357.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38103", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70436-0230-39", "type": "NDC" } ], "description": "VORICONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 75 ML", "billing_class": "facility", "discounted_cash": 183.5, "gross_charge": 282.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38224", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0215-11", "type": "NDC" } ], "description": "PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.4, "gross_charge": 9.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38225", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0226-01", "type": "NDC" } ], "description": "PROPRANOLOL ER 80 MG CAPSULE,24 HR,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.66, "gross_charge": 10.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38263", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2359", "type": "HCPCS" }, { "code": "55150-0308-01", "type": "NDC" } ], "description": "OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 63.54, "gross_charge": 97.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38270", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9075", "type": "HCPCS" }, { "code": "81298-8112-01", "type": "NDC" } ], "description": "CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 313.95, "gross_charge": 483.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38271", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9075", "type": "HCPCS" }, { "code": "10019-0938-25", "type": "NDC" } ], "description": "CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 203.71, "gross_charge": 313.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38285", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1293-83", "type": "NDC" } ], "description": "ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 5.95, "gross_charge": 9.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38303", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0132", "type": "HCPCS" }, { "code": "55150-0259-30", "type": "NDC" } ], "description": "ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 27.14, "gross_charge": 41.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38315", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00597-0075-75", "type": "NDC" } ], "description": "TIOTROPIUM BROMIDE 18 MCG CAPSULE WITH INHALATION DEVICE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 134.71, "gross_charge": 207.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3841", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7914-61", "type": "NDC" } ], "description": "IBUPROFEN 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38421", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0584-11", "type": "NDC" } ], "description": "MIRTAZAPINE 7.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3843", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0446-01", "type": "NDC" } ], "description": "IBUPROFEN 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3844", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0457-01", "type": "NDC" } ], "description": "IBUPROFEN 600 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38488", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-6032-12", "type": "NDC" } ], "description": "FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 4.16, "gross_charge": 6.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38494", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0180", "type": "HCPCS" }, { "code": "58468-0041-01", "type": "NDC" } ], "description": "AGALSIDASE BETA 5 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3684.04, "gross_charge": 5667.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3861", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69315-0134-01", "type": "NDC" } ], "description": "IMIPRAMINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38701", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0780-55", "type": "NDC" } ], "description": "NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 GR", "billing_class": "facility", "discounted_cash": 45.82, "gross_charge": 70.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38703", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0153", "type": "HCPCS" }, { "code": "25021-0318-04", "type": "NDC" } ], "description": "ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 25.16, "gross_charge": 38.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38907", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42799-0208-01", "type": "NDC" } ], "description": "TINIDAZOLE 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.16, "gross_charge": 12.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3897", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0430-15", "type": "NDC" } ], "description": "INDOMETHACIN 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-38977", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0461-60", "type": "NDC" } ], "description": "TROSPIUM 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.48, "gross_charge": 6.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3898", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0431-15", "type": "NDC" } ], "description": "INDOMETHACIN 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-3901", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69344-0102-33", "type": "NDC" } ], "description": "INDOMETHACIN 50 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 314.44, "gross_charge": 483.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-391", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-0292-01", "type": "NDC" } ], "description": "AMILORIDE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39136", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68382-0370-01", "type": "NDC" } ], "description": "NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 23.17, "gross_charge": 35.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39254", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "67546-0111-12", "type": "NDC" } ], "description": "NITAZOXANIDE 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 256.2, "gross_charge": 394.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39265", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9045", "type": "HCPCS" }, { "code": "61703-0339-50", "type": "NDC" } ], "description": "CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 45 ML", "billing_class": "facility", "discounted_cash": 139.62, "gross_charge": 214.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39276", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0595-08", "type": "NDC" } ], "description": "DULOXETINE 30 MG CAPSULE,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39277", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0596-08", "type": "NDC" } ], "description": "DULOXETINE 60 MG CAPSULE,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39301", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0335-30", "type": "NDC" } ], "description": "ABACAVIR 600 MG-LAMIVUDINE 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.73, "gross_charge": 10.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39390", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "40985-0270-86", "type": "NDC" } ], "description": "ARGININE HCL (L-ARGININE) 1,000 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39720", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-6333-80", "type": "NDC" } ], "description": "ACAMPROSATE 333 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.03, "gross_charge": 6.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39744", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "36000-0148-10", "type": "NDC" } ], "description": "FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 25.38, "gross_charge": 39.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39802", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00386-0004-04", "type": "NDC" } ], "description": "NORFLURANE-PENTAFLUOROPROPANE TOPICAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 116 ML", "billing_class": "facility", "discounted_cash": 64.8, "gross_charge": 99.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39918", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3260", "type": "HCPCS" }, { "code": "36000-0244-25", "type": "NDC" } ], "description": "TOBRAMYCIN 40 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 27.3, "gross_charge": 42.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-39975", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0819-42", "type": "NDC" } ], "description": "LANTHANUM 500 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 13.1, "gross_charge": 20.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400291", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7050", "type": "HCPCS" }, { "code": "00338-0049-02", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 42.96, "gross_charge": 66.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400291", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7040", "type": "HCPCS" }, { "code": "00338-0049-03", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 40.24, "gross_charge": 61.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400291", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7030", "type": "HCPCS" }, { "code": "00338-0049-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400292", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0043-03", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.45 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 40.92, "gross_charge": 62.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400292", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0043-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.45 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400293", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7060", "type": "HCPCS" }, { "code": "00338-0017-02", "type": "NDC" } ], "description": "DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 27.14, "gross_charge": 41.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400293", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7060", "type": "HCPCS" }, { "code": "00338-0017-03", "type": "NDC" } ], "description": "DEXTROSE 5 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 24.67, "gross_charge": 37.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400293", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7070", "type": "HCPCS" }, { "code": "00338-0017-04", "type": "NDC" } ], "description": "DEXTROSE 5 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400293", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7060", "type": "HCPCS" }, { "code": "00338-0017-41", "type": "NDC" } ], "description": "DEXTROSE 5 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 50.9, "gross_charge": 78.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400293", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7060", "type": "HCPCS" }, { "code": "00338-0017-48", "type": "NDC" } ], "description": "DEXTROSE 5 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 50.47, "gross_charge": 77.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400294", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7042", "type": "HCPCS" }, { "code": "00338-0089-04", "type": "NDC" } ], "description": "DEXTROSE 5 % AND 0.9 % NACL IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400295", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0085-04", "type": "NDC" } ], "description": "DEXTROSE 5 % AND 0.45 % NACL IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400296", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7120", "type": "HCPCS" }, { "code": "00338-0117-04", "type": "NDC" } ], "description": "LACTATED RINGERS IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400297", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7121", "type": "HCPCS" }, { "code": "00264-7751-00", "type": "NDC" } ], "description": "DEXTROSE 5 % IN LACTATED RINGERS IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 42.28, "gross_charge": 65.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400302", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0023-02", "type": "NDC" } ], "description": "DEXTROSE 10 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 8.09, "gross_charge": 12.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400302", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0023-03", "type": "NDC" } ], "description": "DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 41.6, "gross_charge": 64.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-400302", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0023-04", "type": "NDC" } ], "description": "DEXTROSE 10 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 40.24, "gross_charge": 61.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-40120", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2323", "type": "HCPCS" }, { "code": "64406-0008-01", "type": "NDC" } ], "description": "NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 24235.9, "gross_charge": 37286.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-40158", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16477-0422-06", "type": "NDC" } ], "description": "SELENIUM SULFIDE 2.25 % SHAMPOO", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 180 ML", "billing_class": "facility", "discounted_cash": 99.74, "gross_charge": 153.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4025", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46287-0009-01", "type": "NDC" } ], "description": "ISONIAZID 50 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 447.1, "gross_charge": 687.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4027", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0083-20", "type": "NDC" } ], "description": "ISONIAZID 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-403", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0281", "type": "HCPCS" }, { "code": "00517-9120-25", "type": "NDC" } ], "description": "AMINOCAPROIC ACID 250 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 45.5, "gross_charge": 70.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-40369", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "58914-0501-56", "type": "NDC" } ], "description": "MESALAMINE 1,000 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 75.72, "gross_charge": 116.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-40475", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9264", "type": "HCPCS" }, { "code": "71288-0183-50", "type": "NDC" } ], "description": "PACLITAXEL PROTEIN-BOUND 100 MG INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1995.44, "gross_charge": 3069.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4064", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0082-01", "type": "NDC" } ], "description": "ISOSORBIDE DINITRATE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4065", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0083-01", "type": "NDC" } ], "description": "ISOSORBIDE DINITRATE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4068", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0447-11", "type": "NDC" } ], "description": "ISOSORBIDE DINITRATE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.1, "gross_charge": 6.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-407", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0280", "type": "HCPCS" }, { "code": "00409-5921-01", "type": "NDC" } ], "description": "AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 58.92, "gross_charge": 90.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-40801", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9217", "type": "HCPCS" }, { "code": "62935-0453-45", "type": "NDC" } ], "description": "LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1514.76, "gross_charge": 2330.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-40840026", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2704", "type": "HCPCS" }, { "code": "63323-0269-67", "type": "NDC" } ], "description": "PROPOFOL INFUSION 10 MG/ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 63.54, "gross_charge": 97.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-40872", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" }, { "code": "00641-6057-01", "type": "NDC" } ], "description": "MIDAZOLAM 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 21.71, "gross_charge": 33.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41003", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0221-71", "type": "NDC" } ], "description": "GLYCERIN (ADULT) RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-411026", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9040", "type": "HCPCS" }, { "code": "63323-0136-10", "type": "NDC" } ], "description": "BLEOMYCIN 15 UNIT/ML (IM/SC CONCENTRATION)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 125.48, "gross_charge": 193.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41124", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "38779-1938-05", "type": "NDC" } ], "description": "PHENOL (BULK) 89 % LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 8.19, "gross_charge": 12.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41144", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2248", "type": "HCPCS" }, { "code": "63323-0728-10", "type": "NDC" } ], "description": "MICAFUNGIN 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 74.3, "gross_charge": 114.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41147", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0833-30", "type": "NDC" } ], "description": "ENTECAVIR 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41149", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00003-1614-12", "type": "NDC" } ], "description": "ENTECAVIR 0.05 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 88.92, "gross_charge": 136.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41294", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9185", "type": "HCPCS" }, { "code": "63323-0192-02", "type": "NDC" } ], "description": "FLUDARABINE 50 MG/2 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 241.31, "gross_charge": 371.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41382", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50742-0549-05", "type": "NDC" } ], "description": "FENTANYL 12 MCG/HR TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.38, "gross_charge": 25.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41412", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57896-0181-05", "type": "NDC" } ], "description": "PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 1.01, "gross_charge": 1.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41623", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "52817-0830-04", "type": "NDC" } ], "description": "LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.3 ML", "billing_class": "facility", "discounted_cash": 4.06, "gross_charge": 6.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41628", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90715", "type": "HCPCS" }, { "code": "49281-0400-10", "type": "NDC" } ], "description": "DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 144.56, "gross_charge": 222.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41652", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3243", "type": "HCPCS" }, { "code": "00781-3481-70", "type": "NDC" } ], "description": "TIGECYCLINE 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 64.16, "gross_charge": 98.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41673", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9390", "type": "HCPCS" }, { "code": "25021-0204-05", "type": "NDC" } ], "description": "VINORELBINE 50 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 126.04, "gross_charge": 193.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41787", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "67457-0162-02", "type": "NDC" } ], "description": "SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 245.05, "gross_charge": 377.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41793", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "24201-0201-05", "type": "NDC" } ], "description": "SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 74.16, "gross_charge": 114.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41829", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00527-1943-05", "type": "NDC" } ], "description": "MEMANTINE 2 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 13.75, "gross_charge": 21.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41831", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0418-20", "type": "NDC" } ], "description": "LIDOCAINE 5 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 35.44 GR", "billing_class": "facility", "discounted_cash": 25.77, "gross_charge": 39.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41832", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0788-21", "type": "NDC" } ], "description": "SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.06, "gross_charge": 6.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-41899", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-4215-03", "type": "NDC" } ], "description": "METRONIDAZOLE 1 % TOPICAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 GR", "billing_class": "facility", "discounted_cash": 171.31, "gross_charge": 263.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-42162", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0473-01", "type": "NDC" } ], "description": "PREGABALIN 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.37, "gross_charge": 9.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-42163", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0484-01", "type": "NDC" } ], "description": "PREGABALIN 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.37, "gross_charge": 9.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-42164", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0495-01", "type": "NDC" } ], "description": "PREGABALIN 75 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.37, "gross_charge": 9.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-42219", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68094-0029-62", "type": "NDC" } ], "description": "LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7.5 ML", "billing_class": "facility", "discounted_cash": 1.33, "gross_charge": 2.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4237", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-0040-10", "type": "NDC" } ], "description": "KETAMINE 100 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 47.58, "gross_charge": 73.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4238", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00143-9508-10", "type": "NDC" } ], "description": "KETAMINE 50 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 21.64, "gross_charge": 33.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-42989", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61958-0602-01", "type": "NDC" } ], "description": "EMTRICITABINE 10 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 170 ML", "billing_class": "facility", "discounted_cash": 227.86, "gross_charge": 350.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-431592", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "24571-0101-05", "type": "NDC" } ], "description": "CRRT BK 0/3.5 5000 ML SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 95.39, "gross_charge": 146.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4319", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0114-04", "type": "NDC" } ], "description": "LACTATED RINGERS IRRIGATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 42.8, "gross_charge": 65.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4319", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0137-27", "type": "NDC" } ], "description": "LACTATED RINGERS IRRIGATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3000 ML", "billing_class": "facility", "discounted_cash": 62.72, "gross_charge": 96.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-432", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0037-15", "type": "NDC" } ], "description": "AMITRIPTYLINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-433", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16729-0175-01", "type": "NDC" } ], "description": "AMITRIPTYLINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-43391", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0556-12", "type": "NDC" } ], "description": "LOPINAVIR-RITONAVIR 200 MG-50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.87, "gross_charge": 25.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-435", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0433-01", "type": "NDC" } ], "description": "AMITRIPTYLINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-436", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0444-01", "type": "NDC" } ], "description": "AMITRIPTYLINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-437", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16729-0174-01", "type": "NDC" } ], "description": "AMITRIPTYLINE 75 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4392", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0640", "type": "HCPCS" }, { "code": "71288-0161-20", "type": "NDC" } ], "description": "LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 56.84, "gross_charge": 87.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4393", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0640", "type": "HCPCS" }, { "code": "71288-0163-30", "type": "NDC" } ], "description": "LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 91.55, "gross_charge": 140.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4398", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0581-01", "type": "NDC" } ], "description": "LEUCOVORIN CALCIUM 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.98, "gross_charge": 9.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441001", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7500", "type": "HCPCS" }, { "code": "00000-0009-17", "type": "NDC" } ], "description": "AZATHIOPRINE 25 MG SPLIT TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441008", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0009-18", "type": "NDC" } ], "description": "MERCAPTOPURINE 25 MG SPLIT TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 UN", "billing_class": "facility", "discounted_cash": 4.19, "gross_charge": 6.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441010", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0009-16", "type": "NDC" } ], "description": "MISOPROSTOL 25 MCG SPLIT TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441011", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0009-15", "type": "NDC" } ], "description": "MISOPROSTOL 50 MCG SPLIT TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441022", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "50242-0041-64", "type": "NDC" } ], "description": "ALTEPLASE 10 MG/10 ML IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 541.29, "gross_charge": 832.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441022", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "00000-0003-73", "type": "NDC" } ], "description": "ALTEPLASE 10 MG/10 ML IV SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 1045.33, "gross_charge": 1608.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441023", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0003-12", "type": "NDC" } ], "description": "METHOHEXITAL 100 MG/10 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 40.01, "gross_charge": 61.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441065", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-1053-51", "type": "NDC" } ], "description": "CRRT BGK 2/0 (PRISMASATE) 5000 ML SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 95.39, "gross_charge": 146.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441066", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-1075-01", "type": "NDC" } ], "description": "CRRT B22GK 4/0 (PRISMASATE) 5000 ML SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 95.39, "gross_charge": 146.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441067", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-1104-11", "type": "NDC" } ], "description": "CRRT BGK 4/0/1.2 (PRISMASATE) 5000 ML SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 95.39, "gross_charge": 146.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441068", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-1069-57", "type": "NDC" } ], "description": "CRRT BGK 4/2.5 WITH CALCIUM (PRISMASATE) 5000 ML SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 95.39, "gross_charge": 146.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441069", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0690", "type": "HCPCS" }, { "code": "00000-0006-11", "type": "NDC" } ], "description": "CEFAZOLIN IVPB 2 G IN D5W 50 ML (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 60.0, "gross_charge": 92.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441070", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0017-78", "type": "NDC" } ], "description": "NICARDIPINE 25 MG IN NS 250 ML (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 73.35, "gross_charge": 112.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441071", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0100-74", "type": "NDC" } ], "description": "CLINDAMYCIN 600 MG/1000 ML IN NS IRRIGATION (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.93, "gross_charge": 72.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441075", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2305", "type": "HCPCS" }, { "code": "00000-0014-58", "type": "NDC" } ], "description": "NITROGLYCERIN 100 MCG/ML 10ML SYRINGE (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 23.37, "gross_charge": 35.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441077", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2404", "type": "HCPCS" }, { "code": "00000-0011-12", "type": "NDC" } ], "description": "NICARDIPINE 100 MCG/ML 4ML INJECTION (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 22.23, "gross_charge": 34.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441078", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0008-88", "type": "NDC" } ], "description": "PRIMING SOLUTION 1100 ML (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1100 ML", "billing_class": "facility", "discounted_cash": 65.42, "gross_charge": 100.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441079", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0012-79", "type": "NDC" } ], "description": "CEFAZOLIN 1 GM/500 ML IN NS IRRIGATION (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 44.33, "gross_charge": 68.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441080", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0012-80", "type": "NDC" } ], "description": "GENTAMICIN IRRIGATION 160 MG/1000 ML (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 47.06, "gross_charge": 72.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441081", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0008-89", "type": "NDC" } ], "description": "CARDIOPLEGIC 1000 ML BASE SOLUTION (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 147.13, "gross_charge": 226.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441089", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0013-77", "type": "NDC" } ], "description": "VANCOMYCIN ORAL 250 MG/5 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441090", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0016-32", "type": "NDC" } ], "description": "ADENOSINE 90 MG IN 90 ML NS IVPB (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 90 ML", "billing_class": "facility", "discounted_cash": 466.24, "gross_charge": 717.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441095", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0005-51", "type": "NDC" } ], "description": "CLINDAMYCIN 600 MG/500 ML IN NS IRRIGATION (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 1240.62, "gross_charge": 1908.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441101", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0690", "type": "HCPCS" }, { "code": "00000-0013-68", "type": "NDC" } ], "description": "CEFAZOLIN IVPB 2 G IN NS 50 ML (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 60.0, "gross_charge": 92.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441102", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2404", "type": "HCPCS" }, { "code": "00000-0017-97", "type": "NDC" } ], "description": "NICARDIPINE 5 MG/5 ML SYRINGE (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 40.85, "gross_charge": 62.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441103", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2305", "type": "HCPCS" }, { "code": "00000-0008-87", "type": "NDC" } ], "description": "NITROGLYCERIN 50 MCG/ML 10ML VIAL (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 21.52, "gross_charge": 33.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441117", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0100-72", "type": "NDC" } ], "description": "CEFAZOLIN 1 GM/250 ML IN NS IRRIGATION (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 44.33, "gross_charge": 68.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441118", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0100-73", "type": "NDC" } ], "description": "CLINDAMYCIN 600 MG/250 ML IN NS IRRIGATION (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 46.93, "gross_charge": 72.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441123", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0009-07", "type": "NDC" } ], "description": "ALUM BLADDER IRRIGATION 1% IN STERILE WATER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3000 ML", "billing_class": "facility", "discounted_cash": 324.16, "gross_charge": 498.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441127", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0001-05", "type": "NDC" } ], "description": "GENTAMICIN FORTIFIED OPH DROPS 14 MG/ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7 ML", "billing_class": "facility", "discounted_cash": 40.79, "gross_charge": 62.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441130", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0000-39", "type": "NDC" } ], "description": "LEECH KIT (STERILE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34.64, "gross_charge": 53.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441133", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00338-0221-04", "type": "NDC" } ], "description": "ELECTROLYTE-A INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 40.92, "gross_charge": 62.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441134", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0010-10", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % (COLD) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441137", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9041", "type": "HCPCS" }, { "code": "63020-0049-01", "type": "NDC" } ], "description": "BORTEZOMIB 3.5 MG SOLUTION FOR INJECTION INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4375.48, "gross_charge": 6731.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441138", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0007-11", "type": "NDC" } ], "description": "HYDROXYPROGESTERONE CAPROATE (PF) 250 MG/ML INTRAMUSCULAR INJE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 172.09, "gross_charge": 264.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441139", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7050", "type": "HCPCS" }, { "code": "00338-0049-02", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 57.26, "gross_charge": 88.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441139", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7040", "type": "HCPCS" }, { "code": "00338-0049-03", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.38, "gross_charge": 71.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441139", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7030", "type": "HCPCS" }, { "code": "00338-0049-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441139", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0049-31", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % FOR PRESSURIZED LINE SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 122.62, "gross_charge": 188.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441139", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0049-38", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % FOR PRESSURIZED LINE SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 79.04, "gross_charge": 121.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441140", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3475", "type": "HCPCS" }, { "code": "00000-0100-86", "type": "NDC" } ], "description": "MAGNESIUM SULFATE 2 GRAM/50 ML (4%) IN WATER IVPB (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 39.29, "gross_charge": 60.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441144", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0102-57", "type": "NDC" } ], "description": "VANCOMYCIN INTRAVITREAL SOLUTION 1000 MCG/0.1 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 39.26, "gross_charge": 60.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441148", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0001-44", "type": "NDC" } ], "description": "TOBRAMYCIN FORTIFIED OPH DROPS 13.6 MG/ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7 ML", "billing_class": "facility", "discounted_cash": 49.37, "gross_charge": 75.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441149", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "63323-0285-61", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 2 MG/ML (0.2 %) EPIDURAL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 135.4, "gross_charge": 208.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441150", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "63323-0285-67", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 2 MG/ML (0.2 %) PCEA", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 80.05, "gross_charge": 123.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441151", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-9404-85", "type": "NDC" } ], "description": "AMPICILLIN INJECTION (IM) 1 GM VIAL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.09, "gross_charge": 38.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441153", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0100-95", "type": "NDC" } ], "description": "KETAMINE 50 MG, PROPOFOL 50 MG 10 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 24.54, "gross_charge": 37.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441154", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0703-48", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 45.01, "gross_charge": 69.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441157", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "50242-0085-25", "type": "NDC" } ], "description": "ALTEPLASE BOLUS AND INFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23242.18, "gross_charge": 35757.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441160", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "63600006", "type": "HCPCS" }, { "code": "00000-0101-02", "type": "NDC" } ], "description": "FLUCONAZOLE 600 MG/300 ML (NS) IVPB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 300 ML", "billing_class": "facility", "discounted_cash": 54.54, "gross_charge": 83.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441161", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "63600006", "type": "HCPCS" }, { "code": "00000-0014-54", "type": "NDC" } ], "description": "FLUCONAZOLE 800 MG/400 ML (NS) IVPB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 400 ML", "billing_class": "facility", "discounted_cash": 60.0, "gross_charge": 92.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441166", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0008-81", "type": "NDC" } ], "description": "FORMALIN 4% IRRIGATION IN STERILE WATER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 296.92, "gross_charge": 456.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441170", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0101-03", "type": "NDC" } ], "description": "PHENYLEPHRINE 200 MCG/ML INJECTION (1 ML)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.67, "gross_charge": 37.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441185", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00143-9859-01", "type": "NDC" } ], "description": "CEFTRIAXONE (IM) 250 MG INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.79, "gross_charge": 36.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441186", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00409-7338-21", "type": "NDC" } ], "description": "CEFTRIAXONE (IM) 500 MG INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.46, "gross_charge": 36.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441191", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-9407-78", "type": "NDC" } ], "description": "AMPICILLIN IV 100 MG/ML (WELL BABY CONC)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 32.01, "gross_charge": 49.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441193", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0047-47", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % BLADDER IRRIGATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.38, "gross_charge": 71.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441195", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0102-27", "type": "NDC" } ], "description": "EPINEPHRINE 4 MG IN NS 250 ML INFUSION (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 56.68, "gross_charge": 87.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441201", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0102-34", "type": "NDC" } ], "description": "PROPYLTHIOURACIL 5 MG/ML ORAL SUSPENSION (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.96, "gross_charge": 12.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441202", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7507", "type": "HCPCS" }, { "code": "00000-0102-35", "type": "NDC" } ], "description": "TACROLIMUS 1 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 6.24, "gross_charge": 9.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441203", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0102-36", "type": "NDC" } ], "description": "ZONISAMIDE 10 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441204", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0102-37", "type": "NDC" } ], "description": "LACTATED RINGERS 500ML +LIDO 1%, SOD BICARB (VENOUS ABLATION) 500 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 115.24, "gross_charge": 177.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441208", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1450", "type": "HCPCS" }, { "code": "00000-0010-02", "type": "NDC" } ], "description": "FLUCONAZOLE 100 MG/50 ML IN SOD. CHLORIDE (ISO) IVPB (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 47.74, "gross_charge": 73.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441209", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0008-47", "type": "NDC" } ], "description": "METRONIDAZOLE 250 MG/50 ML-SODIUM CHLORIDE(ISO) IVPB (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 39.72, "gross_charge": 61.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441211", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3101", "type": "HCPCS" }, { "code": "00000-0102-41", "type": "NDC" } ], "description": "TENECTEPLASE 5 MG/10 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.005 GR", "billing_class": "facility", "discounted_cash": 1577.16, "gross_charge": 2426.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441212", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0102-42", "type": "NDC" } ], "description": "LACTATED RINGERS 1000ML+EPI,LIDO 1%, SOD BICARB (VENOUS ABLATION)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 115.24, "gross_charge": 177.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441228", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0111-07", "type": "NDC" } ], "description": "NIMODIPINE 30 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 20.7, "gross_charge": 31.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441229", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-9402-78", "type": "NDC" } ], "description": "AMPICILLIN INJECTION (IM) 250 MG VIAL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.49, "gross_charge": 48.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441230", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-3407-95", "type": "NDC" } ], "description": "AMPICILLIN INJECTION (IM) 500 MG VIAL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.19, "gross_charge": 38.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441231", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1271", "type": "HCPCS" }, { "code": "00000-0102-60", "type": "NDC" } ], "description": "DOXYCYCLINE LYMPHOCELE INJECTON 1000 MG/50 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.77, "gross_charge": 39.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441242", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0102-78", "type": "NDC" } ], "description": "METRONIDAZOLE 1%, MORPHINE 0.5% TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 240 GR", "billing_class": "facility", "discounted_cash": 1026.9, "gross_charge": 1579.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441245", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00000-0102-82", "type": "NDC" } ], "description": "VANCOMYCIN 750 MG IN NS 250 ML IVPB (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 49.79, "gross_charge": 76.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441247", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2151", "type": "HCPCS" }, { "code": "00000-0008-71", "type": "NDC" } ], "description": "MANNITOL 20% IVPB 125 ML (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 62.5 ML", "billing_class": "facility", "discounted_cash": 46.6, "gross_charge": 71.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441258", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0102-95", "type": "NDC" } ], "description": "METRONIDAZOLE/MORPHINE 1%/0.5% CREAM, 30GM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 128.15, "gross_charge": 197.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441259", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9280", "type": "HCPCS" }, { "code": "16729-0116-38", "type": "NDC" } ], "description": "MITOMYCIN 40 MG/20 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.04 GR", "billing_class": "facility", "discounted_cash": 3247.92, "gross_charge": 4996.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441272", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "00000-0103-08", "type": "NDC" } ], "description": "ALTEPLASE 1 MG/ML (INTRAVENTRICULAR-PF) 1 ML- SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 209.95, "gross_charge": 323.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441274", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0019-35", "type": "NDC" } ], "description": "MORPHINE/LIDOCAINE 4%/4% SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 237.12, "gross_charge": 364.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441280", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0103-22", "type": "NDC" } ], "description": "PENICILLIN G POT 2.5 MU IN NS 100 ML (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 19.53, "gross_charge": 30.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441287", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-1010-42", "type": "NDC" } ], "description": "MUPIROCIN 2 % TOPICAL OINTMENT (NASAL TXSUB)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 22 GR", "billing_class": "facility", "discounted_cash": 28.44, "gross_charge": 43.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441289", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2151", "type": "HCPCS" }, { "code": "00000-0008-70", "type": "NDC" } ], "description": "MANNITOL 20% IVPB 62.5 ML (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 62.5 ML", "billing_class": "facility", "discounted_cash": 46.54, "gross_charge": 71.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441290", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9000", "type": "HCPCS" }, { "code": "00000-0103-43", "type": "NDC" } ], "description": "DOXORUBICIN INJECTION (BEAD IMPREGNATION)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 54.96, "gross_charge": 84.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441295", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "63323-0285-67", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 2 MG/ML (0.2 %) PCEA", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 80.05, "gross_charge": 123.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441295", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "63323-0285-20", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION (PAIN BALL)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 50.64, "gross_charge": 77.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441298", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2795", "type": "HCPCS" }, { "code": "70069-0061-25", "type": "NDC" } ], "description": "ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 26.52, "gross_charge": 40.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441299", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00000-0103-53", "type": "NDC" } ], "description": "FENTANYL 10 MCG/ML NASAL SYRINGE (NEONATE/PED)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.28, "gross_charge": 37.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441300", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0103-54", "type": "NDC" } ], "description": "LORAZEPAM 0.5 MG/ML ORAL SYRINGE (NEONATE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441301", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2274", "type": "HCPCS" }, { "code": "00000-0103-56", "type": "NDC" } ], "description": "MORPHINE 0.5 MG/ML INJECTABLE SYRINGE (NEONATE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 21.61, "gross_charge": 33.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441303", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0103-58", "type": "NDC" } ], "description": "MAGIC MOUTHWASH ORAL SUSPENSION (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 180 ML", "billing_class": "facility", "discounted_cash": 14.92, "gross_charge": 22.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441305", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1271", "type": "HCPCS" }, { "code": "63323-0130-13", "type": "NDC" } ], "description": "DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 54.86, "gross_charge": 84.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441307", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0690-30", "type": "NDC" } ], "description": "ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION (ORAL)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 79.88, "gross_charge": 122.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441315", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0109-64", "type": "NDC" } ], "description": "CLONIDINE 20 MCG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 6.56, "gross_charge": 10.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441318", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0104-16", "type": "NDC" } ], "description": "VECURONIUM INJ 0.1 MG/ML FOR PUBS PROCEDURE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 22.78, "gross_charge": 35.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441321", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2371", "type": "HCPCS" }, { "code": "00000-0104-21", "type": "NDC" } ], "description": "PHENYLEPHRINE 500 MCG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 21.81, "gross_charge": 33.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441324", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0105-33", "type": "NDC" } ], "description": "MORPHINE 1% TOPICAL GEL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 7.83, "gross_charge": 12.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441324", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-23", "type": "NDC" } ], "description": "MORPHINE 1% TOPICAL GEL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 50.15, "gross_charge": 77.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441324", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0108-10", "type": "NDC" } ], "description": "MORPHINE 1% TOPICAL GEL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 16.74, "gross_charge": 25.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441325", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-24", "type": "NDC" } ], "description": "MORPHINE 1% IN METRONIDAZOLE 1% TOPICAL GEL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 222.53, "gross_charge": 342.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441326", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-25", "type": "NDC" } ], "description": "MORPHINE 0.5% IN LIDOCAINE TOPICAL SPRAY (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441327", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-26", "type": "NDC" } ], "description": "LIDOCAINE (BUFFERED) TOPICAL SOLUTION (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 14.53, "gross_charge": 22.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441328", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00641-6145-01", "type": "NDC" } ], "description": "DEXAMETHASONE 4 MG/ML INJ (ORAL USE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.3, "gross_charge": 34.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441329", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "63323-0506-01", "type": "NDC" } ], "description": "DEXAMETHASONE 10 MG/ML INJ (ORAL USE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 4.19, "gross_charge": 6.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441330", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7187", "type": "HCPCS" }, { "code": "63833-0615-02", "type": "NDC" } ], "description": "ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT IV KIT (FVIII UNITS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1962.32, "gross_charge": 3018.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441331", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7187", "type": "HCPCS" }, { "code": "63833-0616-02", "type": "NDC" } ], "description": "ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT IV KIT (FVIII UNIITS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3871.27, "gross_charge": 5955.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441332", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7187", "type": "HCPCS" }, { "code": "63833-0617-02", "type": "NDC" } ], "description": "ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT IV KIT (FVIII UNITS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7689.18, "gross_charge": 11829.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441335", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7674", "type": "HCPCS" }, { "code": "00000-0104-47", "type": "NDC" } ], "description": "METHACHOLINE 0.025 MG/ML CHALLENGE SOLUTION (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4000 ML", "billing_class": "facility", "discounted_cash": 106.6, "gross_charge": 164.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441353", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-87", "type": "NDC" } ], "description": "CARDIOPLEGIC SOLUTION + 0 MEQ KCL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 64.77, "gross_charge": 99.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441354", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-88", "type": "NDC" } ], "description": "CARDIOPLEGIC SOLUTION + 15 MEQ KCL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 68.96, "gross_charge": 106.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441355", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-89", "type": "NDC" } ], "description": "CARDIOPLEGIC SOLUTION + 80 MEQ KCL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 86.97, "gross_charge": 133.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441356", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0104-90", "type": "NDC" } ], "description": "GENTAMICIN IRRIGATION 360 MG/3000 ML (CMP PMX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3000 ML", "billing_class": "facility", "discounted_cash": 83.72, "gross_charge": 128.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441371", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-05", "type": "NDC" } ], "description": "FLUCYTOSINE 50 MG/ML ORAL SUSPENSION (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 76.57, "gross_charge": 117.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441378", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9370", "type": "HCPCS" }, { "code": "61703-0309-26", "type": "NDC" } ], "description": "VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION (RND 0.01)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 81.67, "gross_charge": 125.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441379", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7120", "type": "HCPCS" }, { "code": "00338-0117-04", "type": "NDC" } ], "description": "LACTATED RINGERS IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441380", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7030", "type": "HCPCS" }, { "code": "00338-0049-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 39.55, "gross_charge": 60.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441381", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9257", "type": "HCPCS" }, { "code": "00000-0105-26", "type": "NDC" } ], "description": "BEVACIZUMAB (AVASTIN) INTRAVITREAL SOLUTION 1.25 MG/0.05 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.25 ME", "billing_class": "facility", "discounted_cash": 80.21, "gross_charge": 123.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441386", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7030", "type": "HCPCS" }, { "code": "00338-0049-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441387", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-40", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 1) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.54, "gross_charge": 11.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441388", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-41", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 2) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.54, "gross_charge": 11.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441389", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-42", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 3) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.51, "gross_charge": 11.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441391", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-44", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 5) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.48, "gross_charge": 11.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441392", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-45", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 6) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.44, "gross_charge": 11.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441393", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-46", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 7) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.34, "gross_charge": 11.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441394", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-47", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 8) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.51, "gross_charge": 11.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441395", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-48", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 9) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.48, "gross_charge": 11.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441396", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-49", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 10) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.41, "gross_charge": 11.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441397", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-50", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 11) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.51, "gross_charge": 11.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441398", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-51", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 12) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.48, "gross_charge": 11.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441399", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-52", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 13) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.41, "gross_charge": 11.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441400", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-53", "type": "NDC" } ], "description": "PENICILLIN VK (DOSE 14) ORAL DESENSITIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 7.31, "gross_charge": 11.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441402", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" }, { "code": "00000-0105-54", "type": "NDC" } ], "description": "PENICILLIN G POT 100 MG/ML (DESENSITIZATION INGREDIENT A)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 53.5, "gross_charge": 82.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441403", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" }, { "code": "00000-0105-55", "type": "NDC" } ], "description": "PENICILLIN G POT 10 MG/ML (DESENSITIZATION INGREDIENT B)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 53.5, "gross_charge": 82.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441404", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" }, { "code": "00000-0105-56", "type": "NDC" } ], "description": "PENICILLIN G POT 1 MG/ML (DESENSITIZATION INGREDIENT C)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 53.5, "gross_charge": 82.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441405", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" }, { "code": "00000-0105-57", "type": "NDC" } ], "description": "PENICILLIN G POT 0.1 MG/ML (DESENSITIZATION INGREDIENT D)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 53.5, "gross_charge": 82.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441408", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00409-9157-01", "type": "NDC" } ], "description": "PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML ORAL SOLUTION (NEONATE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 10.86, "gross_charge": 16.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441420", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0153", "type": "HCPCS" }, { "code": "63323-0651-02", "type": "NDC" } ], "description": "ADENOSINE INTRACORONARY SOLUTION (CATH LAB USE ONLY)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.0333333333333333 ML", "billing_class": "facility", "discounted_cash": 21.55, "gross_charge": 33.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441423", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "P9047", "type": "HCPCS" }, { "code": "44206-0251-05", "type": "NDC" } ], "description": "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION (IO)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 119.08, "gross_charge": 183.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441424", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "P9045", "type": "HCPCS" }, { "code": "00944-0495-05", "type": "NDC" } ], "description": "ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION (IO)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 160.1, "gross_charge": 246.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441427", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0105-99", "type": "NDC" } ], "description": "VANCOMYCIN ORAL 125 MG/5 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 4.71, "gross_charge": 7.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441429", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1836", "type": "HCPCS" }, { "code": "00338-1055-48", "type": "NDC" } ], "description": "METRONIDAZOLE 5 MG/ML IVPB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 42.58, "gross_charge": 65.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441447", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "27200471", "type": "HCPCS" }, { "code": "00000-0106-31", "type": "NDC" } ], "description": "FECAL MICROBIOTA TRANSPLANT (FMT)LOWER DELIVERY (OPENIBIOME) MICROBIOTA PREP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 1326.49, "gross_charge": 2040.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441485", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0107-03", "type": "NDC" } ], "description": "CODEINE 15 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.7, "gross_charge": 10.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441492", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0166", "type": "HCPCS" }, { "code": "00000-0107-12", "type": "NDC" } ], "description": "EPINEPHRINE 1 MG/ML ANAPHYLAXIS KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 54.57, "gross_charge": 83.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441496", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0713", "type": "HCPCS" }, { "code": "25021-0127-20", "type": "NDC" } ], "description": "CEFTAZIDIME (IM) 1000 MG INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 35.04, "gross_charge": 53.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441510", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "63600006", "type": "HCPCS" }, { "code": "00000-0107-45", "type": "NDC" } ], "description": "FLUCONAZOLE 1400 MG/700 ML IN SODIUM CHLORIDE IVPB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 700 ML", "billing_class": "facility", "discounted_cash": 93.5, "gross_charge": 143.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441511", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "63600006", "type": "HCPCS" }, { "code": "00000-0107-46", "type": "NDC" } ], "description": "FLUCONAZOLE 1200 MG/600 ML IN SODIUM CHLORIDE IVPB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 600 ML", "billing_class": "facility", "discounted_cash": 85.6, "gross_charge": 131.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441512", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "63600006", "type": "HCPCS" }, { "code": "00000-0107-47", "type": "NDC" } ], "description": "FLUCONAZOLE 1000 MG/500 ML IN SODIUM CHLORIDE IVPB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 77.71, "gross_charge": 119.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441517", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2312", "type": "HCPCS" }, { "code": "00000-0107-54", "type": "NDC" } ], "description": "NALOXONE 2 MG/2 ML INTRANASAL KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 114.3, "gross_charge": 175.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441531", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00409-9093-09", "type": "NDC" } ], "description": "FENTANYL 50 MCG/ML NASAL SYRINGE (NEONATE/PED)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 24.05, "gross_charge": 37.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441532", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" }, { "code": "00000-0107-82", "type": "NDC" } ], "description": "MIDAZOLAM 1 MG/ML NASAL SYRINGE (NEONATE/PED)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 21.71, "gross_charge": 33.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441533", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" }, { "code": "00000-0107-83", "type": "NDC" } ], "description": "MIDAZOLAM 5 MG/ML NASAL SYRINGE (NEONATAL/PED)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.26, "gross_charge": 34.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441534", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2151", "type": "HCPCS" }, { "code": "00000-0107-84", "type": "NDC" } ], "description": "MANNITOL 20% IVPB 250 ML (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 71.56, "gross_charge": 110.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441541", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0108-13", "type": "NDC" } ], "description": "MORPHINE NEONATAL 0.2 MG/ML ORAL SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 5.36, "gross_charge": 8.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441547", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0108-33", "type": "NDC" } ], "description": "AMPHOTERICIN INTRAVENTRICULAR 0.1 MG/2 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 49.37, "gross_charge": 75.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441550", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0770", "type": "HCPCS" }, { "code": "00000-0108-36", "type": "NDC" } ], "description": "COLISTIMETHATE SODIUM (COLYMYCIN) INTRAVENTRICULAR 5 MG/2 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 22.56, "gross_charge": 34.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441552", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1580", "type": "HCPCS" }, { "code": "00000-0108-39", "type": "NDC" } ], "description": "GENTAMICIN INTRAVENTRICULAR 5MG/2 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 22.72, "gross_charge": 34.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441554", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0108-42", "type": "NDC" } ], "description": "TOLVAPTAN 7.5 MG SPLIT TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 UN", "billing_class": "facility", "discounted_cash": 533.88, "gross_charge": 821.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441556", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0108-43", "type": "NDC" } ], "description": "MITOMYCIN 0.2 MG/ML TOPICAL OPHTHALMIC SOLUTION (COMPOUND)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 74.1, "gross_charge": 114.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441561", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0108-55", "type": "NDC" } ], "description": "ASCORBIC ACID 1500 MG IN SODIUM CHLORIDE 0.9% 250 ML IVPB (CMP PREMIX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 41.86, "gross_charge": 64.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441562", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0108-56", "type": "NDC" } ], "description": "ASCORBIC ACID 500 MG IN SODIUM CHLORIDE 0.9% 100 ML IVPB (CMP PREMIX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 26.98, "gross_charge": 41.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441626", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0108-98", "type": "NDC" } ], "description": "SELENIUM INJ 4 MCG/ML (CAPS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 21.45, "gross_charge": 33.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441659", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9100", "type": "HCPCS" }, { "code": "63323-0120-20", "type": "NDC" } ], "description": "CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 84.56, "gross_charge": 130.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441665", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0109-26", "type": "NDC" } ], "description": "HYDROXYCHLOROQUINE 25 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8 ML", "billing_class": "facility", "discounted_cash": 8.61, "gross_charge": 13.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441669", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0109-31", "type": "NDC" } ], "description": "KETAMINE ORAL SOLUTION 20 MG/5 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.25 ML", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441671", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "24571-0103-06", "type": "NDC" } ], "description": "CRRT BGK 2/3.5 ( PRISMASOL) 5000 ML SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5000 ML", "billing_class": "facility", "discounted_cash": 106.28, "gross_charge": 163.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441672", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0248", "type": "HCPCS" }, { "code": "61958-2901-02", "type": "NDC" } ], "description": "REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2131.87, "gross_charge": 3279.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441679", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0109-45", "type": "NDC" } ], "description": "MITOMYCIN 0.4 MG/ML BLADDER NECK INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 384.41, "gross_charge": 591.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441679", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0109-44", "type": "NDC" } ], "description": "MITOMYCIN 0.4 MG/ML BLADDER NECK INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 193.7, "gross_charge": 298.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441693", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1120", "type": "HCPCS" }, { "code": "67457-0853-50", "type": "NDC" } ], "description": "ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION (PWD VIAL)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 141.96, "gross_charge": 218.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441694", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "60793-0215-05", "type": "NDC" } ], "description": "THROMBIN (BOVINE) 5,000 UNIT TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 107.51, "gross_charge": 165.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441703", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3010", "type": "HCPCS" }, { "code": "00641-6247-01", "type": "NDC" } ], "description": "FENTANYL INFUSION 50 MCG/ML (PEDS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.73, "gross_charge": 38.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441713", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "63600006", "type": "HCPCS" }, { "code": "00000-0110-18", "type": "NDC" } ], "description": "CALCIUM GLUCONATE 3 GM IN 100 ML NS IVPB (PREMIX)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 32.86, "gross_charge": 50.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441717", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0110-27", "type": "NDC" } ], "description": "METHOHEXITAL 50 MG/5 ML SYRINGE (IR-NEURO USE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 47.06, "gross_charge": 72.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441720", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9280", "type": "HCPCS" }, { "code": "16729-0247-11", "type": "NDC" } ], "description": "MITOMYCIN 20 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.02 GR", "billing_class": "facility", "discounted_cash": 135.98, "gross_charge": 209.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441723", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1200", "type": "HCPCS" }, { "code": "00000-0110-34", "type": "NDC" } ], "description": "DIPHENHYDRAMINE 10 MG/ML (1%) SUBQ SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 25.12, "gross_charge": 38.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441761", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "55150-0234-10", "type": "NDC" } ], "description": "POLYMYXIN B SULFATE 500,000 UNIT/2 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.95, "gross_charge": 49.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441772", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "63323-0276-01", "type": "NDC" } ], "description": "HEPARIN, PORCINE (PF) 1,000 UNIT/ML INJECTION SOLUTION (BMT)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 53.36, "gross_charge": 82.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441780", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0110-82", "type": "NDC" } ], "description": "SODIUM BICARB CONCENTRATED INFUSION 250 MEQ IN 250 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 136.04, "gross_charge": 209.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441781", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2002", "type": "HCPCS" }, { "code": "00338-0409-03", "type": "NDC" } ], "description": "LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441783", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0110-83", "type": "NDC" } ], "description": "SODIUM BICARBONATE MOUTHWASH 5 G/250 ML IN STERILE WATER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 8.32, "gross_charge": 12.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441786", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "27200471", "type": "HCPCS" }, { "code": "00000-0111-19", "type": "NDC" } ], "description": "FECAL MICROBIOTA TRANSPLANT (FMT) STANDARD DOSE LIQUID PREP (MTP-101LR)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 35 ML", "billing_class": "facility", "discounted_cash": 4621.92, "gross_charge": 7110.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441787", "type": "CDM" }, { "code": "272", "type": "RC" }, { "code": "27200471", "type": "HCPCS" }, { "code": "00000-0111-20", "type": "NDC" } ], "description": "FECAL MICROBIOTA TRANSPLANT (FMT) HIGH DOSE LIQUID PREP (MTP-101LF)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 35 ML", "billing_class": "facility", "discounted_cash": 4621.92, "gross_charge": 7110.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441795", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0110-90", "type": "NDC" } ], "description": "DICLOFENAC 50 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.78, "gross_charge": 8.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441796", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0110-96", "type": "NDC" } ], "description": "GLYCERIN 99.5% ANHYDROUS INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 496.4, "gross_charge": 763.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441797", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0111-01", "type": "NDC" } ], "description": "PHENYLEPHRINE 0.2 MG/ML IV SYRINGE 20 ML (RMH ANESTHESIA ONLY)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 105.14, "gross_charge": 161.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441798", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0111-03", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION (CADD PUMP,EPOCH)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441798", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0111-02", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION (CADD PUMP,EPOCH)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441802", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0111-41", "type": "NDC" } ], "description": "METHADONE ORAL SOLUTION 10 MG/1 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 7.05, "gross_charge": 10.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441805", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7504", "type": "HCPCS" }, { "code": "00000-0111-44", "type": "NDC" } ], "description": "ANTITHYMOCYTE GLOBULIN-ATG (ATGAM) TEST DOSE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 219.64, "gross_charge": 337.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441807", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "00000-0107-04", "type": "NDC" } ], "description": "ALTEPLASE 2 MG INTRA-CATHETER SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 452.56, "gross_charge": 696.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441810", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0111-56", "type": "NDC" } ], "description": "HYDROXYUREA 100 MG/ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 11.24, "gross_charge": 17.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441822", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9399", "type": "HCPCS" }, { "code": "00000-0111-72", "type": "NDC" } ], "description": "(COMPOUNDING ONLY) EPCORITAMAB 1.6 MG/2ML IN NS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 2603.93, "gross_charge": 4006.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441826", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "81284-0612-00", "type": "NDC" } ], "description": "TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 28.34, "gross_charge": 43.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441834", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00295-7520-40", "type": "NDC" } ], "description": "CALCIUM GLUCONATE 2.5% (CALGONATE) TOPICAL GEL 25 GM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 GR", "billing_class": "facility", "discounted_cash": 23.4, "gross_charge": 36.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441848", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0049-48", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 % INTRAVENOUS FLUSH (BAG SIZE 100 ML OR LESS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 43.1, "gross_charge": 66.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441849", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2404", "type": "HCPCS" }, { "code": "00000-0112-92", "type": "NDC" } ], "description": "NICARDIPINE 400 MCG/4 ML INJECTION (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 40.2, "gross_charge": 61.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441853", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9280", "type": "HCPCS" }, { "code": "16729-0247-11", "type": "NDC" } ], "description": "MITOMYCIN 20 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.02 GR", "billing_class": "facility", "discounted_cash": 135.98, "gross_charge": 209.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441855", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0113-11", "type": "NDC" } ], "description": "KETAMINE 5% TOPICAL GEL (CMP)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 14.59, "gross_charge": 22.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441859", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7131", "type": "HCPCS" }, { "code": "00338-0054-03", "type": "NDC" } ], "description": "SODIUM CHLORIDE 3 % HYPEROSMOLAR INTRAVENOUS INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 41.6, "gross_charge": 64.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441870", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1611", "type": "HCPCS" }, { "code": "63323-0594-03", "type": "NDC" } ], "description": "GLUCAGON HCL 1 MG/ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 393.28, "gross_charge": 605.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-441875", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00000-0113-42", "type": "NDC" } ], "description": "TRETINOIN 2.5 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 12.61, "gross_charge": 19.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4420", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0453-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 25 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4421", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0464-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 50 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4422", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0475-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 75 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.74, "gross_charge": 5.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4423", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0497-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 100 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4424", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0519-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 125 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4425", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0530-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 150 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4426", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0552-01", "type": "NDC" } ], "description": "LEVOTHYROXINE 200 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.32, "gross_charge": 6.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4450", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64679-0465-51", "type": "NDC" } ], "description": "LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 47.55, "gross_charge": 73.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4451", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-4275-16", "type": "NDC" } ], "description": "LIDOCAINE HCL 5 MG/ML (0.5 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 34.84, "gross_charge": 53.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4452", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "63323-0201-10", "type": "NDC" } ], "description": "LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 25.71, "gross_charge": 39.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4452", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "63323-0201-02", "type": "NDC" } ], "description": "LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 28.86, "gross_charge": 44.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4452", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "63323-0485-27", "type": "NDC" } ], "description": "LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 26.91, "gross_charge": 41.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4452", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-4276-17", "type": "NDC" } ], "description": "LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 31.07, "gross_charge": 47.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4454", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-4277-16", "type": "NDC" } ], "description": "LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 29.06, "gross_charge": 44.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4455", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-4283-11", "type": "NDC" } ], "description": "LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 30.71, "gross_charge": 47.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4459", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-1323-05", "type": "NDC" } ], "description": "LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 40.98, "gross_charge": 63.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-450", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-2020-01", "type": "NDC" } ], "description": "AMOXICILLIN 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4505", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60793-0117-01", "type": "NDC" } ], "description": "LIOTHYRONINE 50 MCG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.68, "gross_charge": 7.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-451", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-2613-01", "type": "NDC" } ], "description": "AMOXICILLIN 500 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-451038", "type": "CDM" }, { "code": "344", "type": "RC" }, { "code": "A9563", "type": "HCPCS" }, { "code": "00000-0100-39", "type": "NDC" } ], "description": "SODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4526", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0333-01", "type": "NDC" } ], "description": "LISINOPRIL 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4528", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-8526-25", "type": "NDC" } ], "description": "LITHIUM CARBONATE 150 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4529", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0221-01", "type": "NDC" } ], "description": "LITHIUM CARBONATE 300 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-454", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00143-9889-15", "type": "NDC" } ], "description": "AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4560", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0690-20", "type": "NDC" } ], "description": "LOPERAMIDE 2 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.36, "gross_charge": 6.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4571", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-3532-44", "type": "NDC" } ], "description": "LORAZEPAM 2 MG/ML ORAL CONCENTRATE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 84.44, "gross_charge": 129.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4572", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-3425-01", "type": "NDC" } ], "description": "LORAZEPAM 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.46, "gross_charge": 8.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4574", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-3427-01", "type": "NDC" } ], "description": "LORAZEPAM 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.49, "gross_charge": 8.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4599", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0901-01", "type": "NDC" } ], "description": "LOXAPINE SUCCINATE 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.1, "gross_charge": 6.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4600", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0902-01", "type": "NDC" } ], "description": "LOXAPINE SUCCINATE 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.68, "gross_charge": 7.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4601", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00527-1394-01", "type": "NDC" } ], "description": "LOXAPINE SUCCINATE 5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461002", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "77333-0951-10", "type": "NDC" } ], "description": "VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461005", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00245-5317-89", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE ER 10 MEQ TABLET SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461008", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62584-0693-11", "type": "NDC" } ], "description": "DOXYCYCLINE HYCLATE 100 MG ORAL SOLID SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461012", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90714", "type": "HCPCS" }, { "code": "49281-0215-15", "type": "NDC" } ], "description": "TETANUS AND DIPHTHERIA TOX (PF) 5-2 LF UNIT IM SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 144.53, "gross_charge": 222.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461013", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" }, { "code": "00641-6061-01", "type": "NDC" } ], "description": "MIDAZOLAM 5 MG/ML INJECTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 23.43, "gross_charge": 36.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461014", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2250", "type": "HCPCS" }, { "code": "00409-0001-25", "type": "NDC" } ], "description": "MIDAZOLAM (PF) 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.1, "gross_charge": 34.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461016", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00641-0367-21", "type": "NDC" } ], "description": "DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.65, "gross_charge": 34.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461019", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51991-0198-99", "type": "NDC" } ], "description": "POLYSACCHARIDE IRON COMPLEX 150 MG IRON CAP SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461020", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-0539-61", "type": "NDC" } ], "description": "MULTIVITAMIN ORAL SOLID SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461021", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51991-0384-90", "type": "NDC" } ], "description": "FOLIC ACID-VIT B6-VIT B12 TABLET SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.45, "gross_charge": 6.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461023", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1171", "type": "HCPCS" }, { "code": "00409-1283-31", "type": "NDC" } ], "description": "HYDROMORPHONE 1 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 24.38, "gross_charge": 37.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461024", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2270", "type": "HCPCS" }, { "code": "00641-6127-01", "type": "NDC" } ], "description": "MORPHINE 10 MG/ML INJECTION SOLUTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 25.45, "gross_charge": 39.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461025", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2175", "type": "HCPCS" }, { "code": "00641-6053-01", "type": "NDC" } ], "description": "MEPERIDINE (PF) 50 MG/ML INJECTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 28.18, "gross_charge": 43.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461027", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00245-5319-89", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE ER 20 MEQ TABLET SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461028", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-4276-01", "type": "NDC" } ], "description": "LIDOCAINE 10 MG/ML (1 %) INJECTION SOLUTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 24.21, "gross_charge": 37.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461029", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00023-0312-04", "type": "NDC" } ], "description": "WHITE PETROLATUM-MINERAL OIL EYE OINTMENT SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 GR", "billing_class": "facility", "discounted_cash": 5.14, "gross_charge": 7.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461030", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2003", "type": "HCPCS" }, { "code": "00409-4277-02", "type": "NDC" } ], "description": "LIDOCAINE 20 MG/ML (2 %) INJECTION SOLUTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 34.03, "gross_charge": 52.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461032", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2710", "type": "HCPCS" }, { "code": "63323-0413-10", "type": "NDC" } ], "description": "NEOSTIGMINE METHYLSULFATE 0.5 MG/ML INJECTION SOLUTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.07, "gross_charge": 33.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461034", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8530", "type": "HCPCS" }, { "code": "00054-0382-25", "type": "NDC" } ], "description": "CYCLOPHOSPHAMIDE 25 MG ORAL SOLID SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.06, "gross_charge": 26.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461035", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8530", "type": "HCPCS" }, { "code": "00054-0383-25", "type": "NDC" } ], "description": "CYCLOPHOSPHAMIDE 50 MG ORAL SOLID SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 28.83, "gross_charge": 44.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461036", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0597-01", "type": "NDC" } ], "description": "NIFEDIPINE ER 30 MG TABLET, EXT RELEASE ORAL SOLID SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.42, "gross_charge": 6.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461037", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0598-11", "type": "NDC" } ], "description": "NIFEDIPINE ER 60 MG TABLET, EXT RELEASE ORAL SOLID SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.73, "gross_charge": 10.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461038", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0603-11", "type": "NDC" } ], "description": "NIFEDIPINE ER 90 MG TABLET, EXT RELEASE ORAL SOLID SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.7, "gross_charge": 11.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461041", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-0404-01", "type": "NDC" } ], "description": "MORPHINE CONCENTRATE (20 MG/ML) ORAL SOLUTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461042", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "66689-0327-02", "type": "NDC" } ], "description": "DIGOXIN 50 MCG/ML ORAL SOLUTION SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 ML", "billing_class": "facility", "discounted_cash": 140.66, "gross_charge": 216.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461043", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00591-3543-60", "type": "NDC" } ], "description": "BUPROPION HCL SR 150 MG TABLET SORD", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.84, "gross_charge": 5.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461045", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2004", "type": "HCPCS" }, { "code": "63323-0489-27", "type": "NDC" } ], "description": "LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.34, "gross_charge": 37.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461050", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0957-10", "type": "NDC" } ], "description": "PHENYLEPHRINE 1 MG/10 ML (100 MCG/ML) IN 0.9 % SOD.CHLORIDE IV SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 23.04, "gross_charge": 35.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461056", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0525", "type": "HCPCS" }, { "code": "52565-0052-10", "type": "NDC" } ], "description": "CEFOTETAN INJ (SORD FOR COMPOUNDING)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 145.73, "gross_charge": 224.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461073", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7999", "type": "HCPCS" }, { "code": "69374-0925-10", "type": "NDC" } ], "description": "EPINEPHRINE 1 MG/10 ML (100 MCG/ML) INJECTION (NSORD)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 26.32, "gross_charge": 40.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461074", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0330", "type": "HCPCS" }, { "code": "73177-0116-03", "type": "NDC" } ], "description": "SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 73.64, "gross_charge": 113.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461075", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9260", "type": "HCPCS" }, { "code": "61703-0350-38", "type": "NDC" } ], "description": "METHOTREXATE SODIUM 25 MG/ML INJECTION FOR ECTOPIC PREGNANCY (SORD)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 65.98, "gross_charge": 101.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-461080", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "63323-0506-01", "type": "NDC" } ], "description": "DEXAMETHASONE 10 MG/ML INJ (ORAL USE)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 23.27, "gross_charge": 35.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-464", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0285", "type": "HCPCS" }, { "code": "39822-1055-05", "type": "NDC" } ], "description": "AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 135.78, "gross_charge": 208.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-469", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-9404-95", "type": "NDC" } ], "description": "AMPICILLIN 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.09, "gross_charge": 38.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-471", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-9401-78", "type": "NDC" } ], "description": "AMPICILLIN 125 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 34.0, "gross_charge": 52.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4712", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0741-38", "type": "NDC" } ], "description": "MAGNESIUM CITRATE ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 296 ML", "billing_class": "facility", "discounted_cash": 8.84, "gross_charge": 13.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-472", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-9408-95", "type": "NDC" } ], "description": "AMPICILLIN 2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27.62, "gross_charge": 42.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4720", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3475", "type": "HCPCS" }, { "code": "63323-0642-20", "type": "NDC" } ], "description": "MAGNESIUM SULFATE 500 MG/ML (50 %) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 22.78, "gross_charge": 35.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-473", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "00781-9402-78", "type": "NDC" } ], "description": "AMPICILLIN INJECTION (IM) 250 MG VIAL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.49, "gross_charge": 48.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-474", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0290", "type": "HCPCS" }, { "code": "44567-0101-10", "type": "NDC" } ], "description": "AMPICILLIN 500 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.38, "gross_charge": 37.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4749", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2151", "type": "HCPCS" }, { "code": "00338-0357-03", "type": "NDC" } ], "description": "MANNITOL 20 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 62.5 ML", "billing_class": "facility", "discounted_cash": 46.6, "gross_charge": 71.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4750", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2151", "type": "HCPCS" }, { "code": "63323-0024-29", "type": "NDC" } ], "description": "MANNITOL 25 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 24.93, "gross_charge": 38.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-481003", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1450", "type": "HCPCS" }, { "code": "00338-6045-37", "type": "NDC" } ], "description": "FLUCONAZOLE 2 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 55.09, "gross_charge": 84.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-481003", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1450", "type": "HCPCS" }, { "code": "00338-6046-48", "type": "NDC" } ], "description": "FLUCONAZOLE 2 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 53.17, "gross_charge": 81.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-481004", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1953", "type": "HCPCS" }, { "code": "67457-0265-00", "type": "NDC" } ], "description": "LEVETIRACETAM 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 83.95, "gross_charge": 129.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-481005", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1953", "type": "HCPCS" }, { "code": "67457-0266-00", "type": "NDC" } ], "description": "LEVETIRACETAM 15 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 98.12, "gross_charge": 150.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-481006", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1953", "type": "HCPCS" }, { "code": "67457-0255-00", "type": "NDC" } ], "description": "LEVETIRACETAM 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 69.81, "gross_charge": 107.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4854", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0105-21", "type": "NDC" } ], "description": "MEDROXYPROGESTERONE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.23, "gross_charge": 8.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4855", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59762-0055-01", "type": "NDC" } ], "description": "MEDROXYPROGESTERONE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4870", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00555-0606-02", "type": "NDC" } ], "description": "MEGESTROL 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4871", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7236-61", "type": "NDC" } ], "description": "MEGESTROL 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4903", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2175", "type": "HCPCS" }, { "code": "00641-6052-01", "type": "NDC" } ], "description": "MEPERIDINE (PF) 25 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 27.95, "gross_charge": 43.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4904", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2175", "type": "HCPCS" }, { "code": "00641-6053-25", "type": "NDC" } ], "description": "MEPERIDINE (PF) 50 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 28.18, "gross_charge": 43.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491002", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-50", "type": "NDC" } ], "description": "INV ERLOTINIB/PLACEBO 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491003", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-52", "type": "NDC" } ], "description": "INV ERLOTINIB/PLACEBO 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491004", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-53", "type": "NDC" } ], "description": "INV ERLOTINIB/PLACEBO 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491005", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0011-04", "type": "NDC" } ], "description": "INV CLOPIDROGEL/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491006", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0013-90", "type": "NDC" } ], "description": "INV PRASUGREL/PLACEBO 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491007", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0013-91", "type": "NDC" } ], "description": "INV PRASUGREL/PLACEBO 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491008", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0014-21", "type": "NDC" } ], "description": "INV DULOXETINE/PLACEBO 30 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491009", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-54", "type": "NDC" } ], "description": "INV ERLOTINIB 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491010", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-55", "type": "NDC" } ], "description": "INV ERLOTINIB 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491011", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-56", "type": "NDC" } ], "description": "INV ERLOTINIB 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491012", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-11", "type": "NDC" } ], "description": "INV LENALIDOMIDE 5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491013", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0014-27", "type": "NDC" } ], "description": "INV CB-183,315/PLACEBO/VANCOMYCIN CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491014", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0014-28", "type": "NDC" } ], "description": "INV CB-183,315/PLACEBO/VANCOMYCIN CAPSULE (KIT)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491015", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0014-59", "type": "NDC" } ], "description": "INV CELECOXIB/PLACEBO 400 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491016", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0014-95", "type": "NDC" } ], "description": "INV LISINOPRIL/CARVEDILOL CR/PLACEBO 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491017", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-29", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.9% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491017", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-24", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.9% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491017", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-26", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.9% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491017", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-30", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.9% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491017", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-25", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.9% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491017", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-27", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.9% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 150 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491018", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-77", "type": "NDC" } ], "description": "INV EVEROLIMUS/PLACEBO 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491019", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-15", "type": "NDC" } ], "description": "INV LENALIDOMIDE 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491020", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-31", "type": "NDC" } ], "description": "INV DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491020", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-35", "type": "NDC" } ], "description": "INV DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491020", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-34", "type": "NDC" } ], "description": "INV DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491020", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-32", "type": "NDC" } ], "description": "INV DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491020", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-36", "type": "NDC" } ], "description": "INV DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491020", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-33", "type": "NDC" } ], "description": "INV DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 150 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491021", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0016-42", "type": "NDC" } ], "description": "INV PAZOPANIB/PLACEBO 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491022", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0016-65", "type": "NDC" } ], "description": "INV TICAGRELOR/PLACEBO 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491023", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0016-66", "type": "NDC" } ], "description": "INV TICAGRELOR/PLACEBO 90 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491024", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-98", "type": "NDC" } ], "description": "INV CLOPIDOGREL/PLACEBO 75 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491025", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0017-14", "type": "NDC" } ], "description": "INV RANOLAZINE/PLACEBO 500 MG TB12 TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491026", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0017-92", "type": "NDC" } ], "description": "INV EFLORNITHINE/PLACEBO 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491027", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-09", "type": "NDC" } ], "description": "INV LENALIDOMIDE 2.5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491028", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0017-93", "type": "NDC" } ], "description": "INV SULINDAC/PLACEBO 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491029", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-73", "type": "NDC" } ], "description": "INV SMT 199969/PLACEBO/VANCOMYCIN CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491030", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9055", "type": "HCPCS" }, { "code": "00000-0005-60", "type": "NDC" } ], "description": "INV CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491031", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-83", "type": "NDC" } ], "description": "INV ASPIRIN/PLACEBO 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491032", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-96", "type": "NDC" } ], "description": "INV ASPIRIN/PLACEBO 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491033", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0000-74", "type": "NDC" } ], "description": "INV AZTREONAM 2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491034", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9355", "type": "HCPCS" }, { "code": "00000-0005-70", "type": "NDC" } ], "description": "INV TRASTUZUMAB 440 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491035", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-40", "type": "NDC" } ], "description": "INV LACTATED RINGERS INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491035", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-39", "type": "NDC" } ], "description": "INV LACTATED RINGERS INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491035", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0009-95", "type": "NDC" } ], "description": "INV LACTATED RINGERS INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491036", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9395", "type": "HCPCS" }, { "code": "00000-0005-86", "type": "NDC" } ], "description": "INV FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491037", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-52", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491038", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0006-10", "type": "NDC" } ], "description": "INV SORAFENIB TOSYLATE (BAY 43-9006) 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491040", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0006-73", "type": "NDC" } ], "description": "INV AZTREONAM 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491041", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "Q9957", "type": "HCPCS" }, { "code": "00000-0007-12", "type": "NDC" } ], "description": "INV PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491044", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-26", "type": "NDC" } ], "description": "INV ART-123/PLACEBO 6 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491045", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9035", "type": "HCPCS" }, { "code": "00000-0010-49", "type": "NDC" } ], "description": "INV BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491046", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0019-04", "type": "NDC" } ], "description": "INV ARMODAFINIL 150 MG/ARMODAFINIL 250 MG/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491047", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0019-13", "type": "NDC" } ], "description": "INV METFORMIN/PLACEBO 850 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491048", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0015-67", "type": "NDC" } ], "description": "INV ELESCLOMOL 250 MG/5.54 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491049", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0019-20", "type": "NDC" } ], "description": "INV SERELAXIN/PLACEBO 3.5 MG/3.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491050", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0015-90", "type": "NDC" } ], "description": "INV INDOCYANINE GREEN 25 MG/5 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491051", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3095", "type": "HCPCS" }, { "code": "00000-0019-24", "type": "NDC" } ], "description": "INV TELAVANCIN 750 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491052", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "00000-0015-92", "type": "NDC" } ], "description": "INV ALTEPLASE/PLACEBO 50 MG/50 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491053", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00000-0016-04", "type": "NDC" } ], "description": "INV VANCOMYCIN 1,000 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491054", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "00000-0017-33", "type": "NDC" } ], "description": "INV HEPARIN/PLACEBO 1,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491056", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-11", "type": "NDC" } ], "description": "INV TREBANANIB/PLACEBO 30 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491058", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-34", "type": "NDC" } ], "description": "INV CLOSTRIDIUM DIFFICILE TOXOID VACCINE/PLACEBO", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491059", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0278", "type": "HCPCS" }, { "code": "00000-0018-47", "type": "NDC" } ], "description": "INV AMIKACIN/PLACEBO 125 MG/ML SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491060", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0017-34", "type": "NDC" } ], "description": "INV POLYMYXIN-B/SHAM CARTRIDGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491061", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00000-0018-66", "type": "NDC" } ], "description": "INV DEXAMETHASONE 4 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491062", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-84", "type": "NDC" } ], "description": "INV ALTEPLASE/PLACEBO BOLUS FROM THE BAG", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491063", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0008-26", "type": "NDC" } ], "description": "INV METRONIDAZOLE IN NACL 500 MG/100 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491064", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0019-03", "type": "NDC" } ], "description": "INV TRC105 7 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491073", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-54", "type": "NDC" } ], "description": "INV NEBULIZER RESERVOIR AND CAP KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491076", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0878", "type": "HCPCS" }, { "code": "00000-0004-71", "type": "NDC" } ], "description": "INV DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491077", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0690", "type": "HCPCS" }, { "code": "00000-0006-77", "type": "NDC" } ], "description": "INV CEFAZOLIN 1 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491080", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-55", "type": "NDC" } ], "description": "INV PDDS CLINICAL CONTROL MODULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491081", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-56", "type": "NDC" } ], "description": "INV PDDS CLINICAL ON-VENT ADAPTOR KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491083", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0018-58", "type": "NDC" } ], "description": "INV PDDS CLINICAL HANDHELD ADAPTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491084", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0019-27", "type": "NDC" } ], "description": "INV USL261/PLACEBO 5 MG/0.1 ML NASAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491094", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-04", "type": "NDC" } ], "description": "INV FARLETUZUMAB/PLACEBO 5 MG/ML INFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491094", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-03", "type": "NDC" } ], "description": "INV FARLETUZUMAB/PLACEBO 5 MG/ML INFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491104", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2919", "type": "HCPCS" }, { "code": "00000-0113-21", "type": "NDC" } ], "description": "INV METHYLYPREDNISOLONE SOD SUC (PF) 125 MG/2 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491107", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-24", "type": "NDC" } ], "description": "INV KEYHOLE LIMPET HEMOCYANIN 1 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491108", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2350", "type": "HCPCS" }, { "code": "00000-0103-25", "type": "NDC" } ], "description": "INV OCRELIZUMAB 30 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491112", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-28", "type": "NDC" } ], "description": "INV VELIPARIB/PLACEBO 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491113", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-29", "type": "NDC" } ], "description": "INV VELIPARIB/PLACEBO 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491117", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-32", "type": "NDC" } ], "description": "INV POLYETHYLENE GLYCOL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4000 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491118", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-33", "type": "NDC" } ], "description": "INV MAGNESIUM CITRATE SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 296 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491119", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-34", "type": "NDC" } ], "description": "INV SER-109 CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491120", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-35", "type": "NDC" } ], "description": "INV SER-109/PLACEBO CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491121", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-36", "type": "NDC" } ], "description": "INV SYN-004/PLACEBO 75 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 40 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491122", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-37", "type": "NDC" } ], "description": "INV CHOLESTYRAMINE-ASPARTAME 4 GM PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491123", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-38", "type": "NDC" } ], "description": "INV ACTIVATED CHARCOAL-SORBITOL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 240 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491124", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-39", "type": "NDC" } ], "description": "INV PONESIMOD/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491125", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-40", "type": "NDC" } ], "description": "INV PONESIMOD 20 MG OR TERIFLUNOMIDE 14 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491126", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-70", "type": "NDC" } ], "description": "INV TERIFLUNOMIDE/PLACEBO 14 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 35 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491128", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-48", "type": "NDC" } ], "description": "INV TRC105 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491128", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-47", "type": "NDC" } ], "description": "INV TRC105 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491129", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9271", "type": "HCPCS" }, { "code": "00000-0103-49", "type": "NDC" } ], "description": "INV PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491131", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-52", "type": "NDC" } ], "description": "INV CERITINIB 150 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 35 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491132", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-55", "type": "NDC" } ], "description": "INV LJPC-501/PLACEBO 2.5 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491139", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1300", "type": "HCPCS" }, { "code": "00000-0103-61", "type": "NDC" } ], "description": "INV ECULIZUMAB 10 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491140", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1300", "type": "HCPCS" }, { "code": "00000-0103-62", "type": "NDC" } ], "description": "INV ECULIZUMAB/PLACEBO 10 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491143", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-41", "type": "NDC" } ], "description": "INV ASPIRIN EC 81 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491144", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-64", "type": "NDC" } ], "description": "INV ASPIRIN EC/PLACEBO 81 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491145", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-65", "type": "NDC" } ], "description": "INV TICAGRELOR 90 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491146", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-66", "type": "NDC" } ], "description": "INV DCVAX-L 1.25 MILLION CELLS INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491147", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-67", "type": "NDC" } ], "description": "INV DCVAX-L/PLACEBO 1.25 MILLION CELLS INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491148", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-70", "type": "NDC" } ], "description": "INV JVS-100/PLACEBO 1 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491149", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-71", "type": "NDC" } ], "description": "INV CAP-1002/PLACEBO 25 MILLION CELLS/10 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491150", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-72", "type": "NDC" } ], "description": "INV NITROGLYCERIN 400 MCG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491151", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "00000-0103-73", "type": "NDC" } ], "description": "INV HEPARIN 1000 UNIT/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491155", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0103-97", "type": "NDC" } ], "description": "INV STAPHYLOCOCCUS AUREUS 4-ANTIGEN VACCINE/PLACEBO INJ", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491156", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1595", "type": "HCPCS" }, { "code": "00000-0104-17", "type": "NDC" } ], "description": "INV GLATIRAMER 20 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 600 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491157", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1595", "type": "HCPCS" }, { "code": "00000-0104-18", "type": "NDC" } ], "description": "INV GLATIRAMER 40 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 12 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491158", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9299", "type": "HCPCS" }, { "code": "00000-0104-27", "type": "NDC" } ], "description": "INV NIVOLUMAB 10 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491160", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-29", "type": "NDC" } ], "description": "INV ASPIRIN EC 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491161", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-31", "type": "NDC" } ], "description": "INV RIVAROXOBAN/PLACEBO 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491162", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-33", "type": "NDC" } ], "description": "INV CEDIRANIB 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491163", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-34", "type": "NDC" } ], "description": "INV CEDIRANIB 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491164", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-35", "type": "NDC" } ], "description": "INV OLAPARIB 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491165", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-36", "type": "NDC" } ], "description": "INV OLAPARIB 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491170", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2290", "type": "HCPCS" }, { "code": "00000-0104-46", "type": "NDC" } ], "description": "INV NAFCILLIN 200 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491173", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-23", "type": "NDC" } ], "description": "INV SELEPRESSIN/PLACEBO INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491174", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1644", "type": "HCPCS" }, { "code": "00264-9587-20", "type": "NDC" } ], "description": "INV HEPARIN 25,000 UNITS IN DEXTROSE 5% 250 ML INFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 79.04, "gross_charge": 121.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491177", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-53", "type": "NDC" } ], "description": "INV BMS-986141/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491178", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-54", "type": "NDC" } ], "description": "INV RIVAROXOBAN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491179", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-55", "type": "NDC" } ], "description": "INV RIVAROXOBAN 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491180", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-56", "type": "NDC" } ], "description": "INV RIVAROXOBAN 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491189", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-64", "type": "NDC" } ], "description": "INV POLYMYXIN-B CARTRIDGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491192", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-65", "type": "NDC" } ], "description": "INV ENTINOSTAT/PLACEBO 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491193", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-66", "type": "NDC" } ], "description": "INV ENTINOSTAT/PLACEBO 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491195", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-67", "type": "NDC" } ], "description": "INV EXEMESTANE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491196", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9302", "type": "HCPCS" }, { "code": "00000-0104-69", "type": "NDC" } ], "description": "INV OFATUMUMAB/PLACEBO 20 MG/0.4 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491197", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00000-0104-72", "type": "NDC" } ], "description": "INV ENOXAPARIN 30 MG/0.3 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491198", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00000-0104-73", "type": "NDC" } ], "description": "INV ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491199", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00000-0104-74", "type": "NDC" } ], "description": "INV ENOXAPARIN 60 MG/0.6 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491200", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00000-0104-75", "type": "NDC" } ], "description": "INV ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491201", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00000-0104-76", "type": "NDC" } ], "description": "INV ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491202", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00000-0104-77", "type": "NDC" } ], "description": "INV ENOXAPARIN 120 MG/0.8 ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491203", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1650", "type": "HCPCS" }, { "code": "00000-0104-78", "type": "NDC" } ], "description": "INV ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491205", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-79", "type": "NDC" } ], "description": "INV DROXIDOPA 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491206", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-80", "type": "NDC" } ], "description": "INV DROXIDOPA 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491207", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-81", "type": "NDC" } ], "description": "INV DROXIDOPA 300 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491208", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-82", "type": "NDC" } ], "description": "INV DROXIDOPA/PLACEBO 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491209", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-83", "type": "NDC" } ], "description": "INV DROXIDOPA/PLACEBO 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491210", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-84", "type": "NDC" } ], "description": "INV DROXIDOPA/PLACEBO 300 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491219", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0104-95", "type": "NDC" } ], "description": "INV SER-262/PLACEBO CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491220", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "60635-0118-01", "type": "NDC" } ], "description": "POLIDOCANOL 1 % INTRAVENOUS FOAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 45 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491221", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "60635-0123-01", "type": "NDC" } ], "description": "INV VARITHENA ADMINISTRATION PACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491222", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-00", "type": "NDC" } ], "description": "INV TRAMETINIB 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491223", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-01", "type": "NDC" } ], "description": "INV TRAMETINIB 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491225", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9354", "type": "HCPCS" }, { "code": "00000-0105-02", "type": "NDC" } ], "description": "INV ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491228", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-04", "type": "NDC" } ], "description": "INV CRIZOTINIB 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491230", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9063", "type": "HCPCS" }, { "code": "00000-0105-06", "type": "NDC" } ], "description": "INV MIRVETUXIMAB SORAVTANSINE 5 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491234", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-20", "type": "NDC" } ], "description": "INV PREDNISOLONE ACETATE 1% OPHTHALMIC SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491235", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-21", "type": "NDC" } ], "description": "INV REFRESH OPTIVE ADVANCED (PRESERVATIVE-FREE) OPHTHALMIC SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491236", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9057", "type": "HCPCS" }, { "code": "00000-0105-37", "type": "NDC" } ], "description": "INV COPANLISIB (BAY 80-6946) 15 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491239", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-60", "type": "NDC" } ], "description": "INV ATORVASTATIN/PLACEBO 40 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 180 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491240", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-64", "type": "NDC" } ], "description": "INV AERUCIN/PLACEBO (AERUBUMAB, AR-105) 27.5 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491242", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-66", "type": "NDC" } ], "description": "INV EFLORNITHINE 150 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 463 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491243", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-67", "type": "NDC" } ], "description": "INV DONEPEZIL/PLACEBO 5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 42 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491244", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-71", "type": "NDC" } ], "description": "INV ASPIRIN/PLACEBO 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491245", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-72", "type": "NDC" } ], "description": "INV TRIAPINE 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491248", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-74", "type": "NDC" } ], "description": "INV TAK-700 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491249", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-79", "type": "NDC" } ], "description": "INV PONESIMOD/PLACEBO 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491250", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9022", "type": "HCPCS" }, { "code": "00000-0105-80", "type": "NDC" } ], "description": "INV ATEZOLIZUMAB/PLACEBO 1200 MG/20 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491252", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-81", "type": "NDC" } ], "description": "INV YKP3089 (CENOBAMATE) 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491253", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-82", "type": "NDC" } ], "description": "INV YKP3089 (CENOBAMATE) 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491254", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-83", "type": "NDC" } ], "description": "INV YKP3089 (CENOBAMATE) 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491255", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-84", "type": "NDC" } ], "description": "INV YKP3089 (CENOBAMATE) 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491256", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-92", "type": "NDC" } ], "description": "INV O.N.E. MULTIVITAMIN CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491257", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-93", "type": "NDC" } ], "description": "INV CALCIUM-VIT D3 150 MG-133 UNIT CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491258", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-94", "type": "NDC" } ], "description": "INV AFATINIB 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491259", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-95", "type": "NDC" } ], "description": "INV AFATINIB 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491260", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0105-96", "type": "NDC" } ], "description": "INV AFATINIB 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491262", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9047", "type": "HCPCS" }, { "code": "00000-0106-00", "type": "NDC" } ], "description": "INV CARFILZOMIB 60 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491264", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-01", "type": "NDC" } ], "description": "INV LLG783/PLACEBO 150 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491266", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-03", "type": "NDC" } ], "description": "INV OMECAMTIV MECARBIL/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491267", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-04", "type": "NDC" } ], "description": "INV BUPROPION XL/PLACEBO 24 HR CAPSULE 150 MG", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 7 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491268", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-07", "type": "NDC" } ], "description": "INV APIXABAN 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 74 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491269", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-08", "type": "NDC" } ], "description": "INV APIXABAN 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 74 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491271", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1645", "type": "HCPCS" }, { "code": "00000-0106-09", "type": "NDC" } ], "description": "INV DALTEPARIN 2500 UNITS/0.2ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491272", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1645", "type": "HCPCS" }, { "code": "00000-0106-10", "type": "NDC" } ], "description": "INV DALTEPARIN 5000 UNITS/0.2 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491273", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1645", "type": "HCPCS" }, { "code": "00000-0106-11", "type": "NDC" } ], "description": "INV DALTEPARIN 7500 UNITS/0.3 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491274", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1645", "type": "HCPCS" }, { "code": "00000-0106-12", "type": "NDC" } ], "description": "INV DALTEPARIN 10,000 UNITS/1 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491275", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1645", "type": "HCPCS" }, { "code": "00000-0106-13", "type": "NDC" } ], "description": "INV DALTEPARIN 12,500 UNITS/0.5 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491276", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1645", "type": "HCPCS" }, { "code": "00000-0106-14", "type": "NDC" } ], "description": "INV DALTEPARIN 15,000 UNITS/0.6 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491277", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1645", "type": "HCPCS" }, { "code": "00000-0106-15", "type": "NDC" } ], "description": "INV DALTEPARIN 18,000 UNITS/0.72 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.72 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491282", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-34", "type": "NDC" } ], "description": "INV OPICINUMAB (BIIB003)/PLACEBO 200 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491284", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00000-0106-36", "type": "NDC" } ], "description": "INV DEXAMETHASONE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491285", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1200", "type": "HCPCS" }, { "code": "00000-0106-37", "type": "NDC" } ], "description": "INV DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491286", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-05", "type": "NDC" } ], "description": "INV TERIFLUNOMIDE/PLACEBO 14 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 42 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491290", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1568", "type": "HCPCS" }, { "code": "00000-0106-43", "type": "NDC" } ], "description": "INV IMMUNE GLOBULIN (IGG)(OCTAGAM) 10% INFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491291", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1568", "type": "HCPCS" }, { "code": "00000-0106-48", "type": "NDC" } ], "description": "INV IMMUNE GLOBULIN (IGG)/PLACEBO (OCTAGAM/PLACEBO) 10% INFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491292", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00000-0106-52", "type": "NDC" } ], "description": "INV DIMETHYL FUMARATE 120 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491294", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-54", "type": "NDC" } ], "description": "INV PEGINTERFERON BETA-1A 63 MCG/0.5 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491295", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-55", "type": "NDC" } ], "description": "INV PEGINTERFERON BETA-1A 94 MCG/0.5 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491296", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-56", "type": "NDC" } ], "description": "INV PEGINTERFERON BETA-1A 125 MCG/0.5 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491297", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J8540", "type": "HCPCS" }, { "code": "00000-0106-78", "type": "NDC" } ], "description": "INV DEXAMETHASONE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491298", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J8540", "type": "HCPCS" }, { "code": "00000-0106-79", "type": "NDC" } ], "description": "INV DEXAMETHASONE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491299", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-80", "type": "NDC" } ], "description": "INV PANTOPRAZOLE EC 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491300", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-81", "type": "NDC" } ], "description": "INV DIPHENHYDRAMINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491301", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-83", "type": "NDC" } ], "description": "INV PONESIMOD 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 36 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491302", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-84", "type": "NDC" } ], "description": "INV PONESIMOD TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 17 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491303", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9173", "type": "HCPCS" }, { "code": "00000-0106-86", "type": "NDC" } ], "description": "INV DURVALUMAB 50 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491305", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9347", "type": "HCPCS" }, { "code": "00000-0106-87", "type": "NDC" } ], "description": "INV TREMELIMUMAB 20 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.75 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491307", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-00", "type": "NDC" } ], "description": "INV VIS410/PLACEBO 25 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491308", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-01", "type": "NDC" } ], "description": "INV VIS410 2000 MG/VIS410 4000MG/PLACEBO INFUSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491309", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-92", "type": "NDC" } ], "description": "INV DIPHENHYDRAMINE 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491310", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-93", "type": "NDC" } ], "description": "INV ACETYLSALICYLIC ACID 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491312", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-95", "type": "NDC" } ], "description": "INV OSELTAMIVIR 30 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491313", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-96", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE (NS) 0.9% FLUSH SYRINGE 26 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 26 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491315", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2329", "type": "HCPCS" }, { "code": "00000-0106-98", "type": "NDC" } ], "description": "INV UBLITUXIMAB/PLACEBO 25 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491318", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0106-99", "type": "NDC" } ], "description": "INV IBUPROFEN 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491320", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-14", "type": "NDC" } ], "description": "INV PROCHLORPERAZINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491321", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-16", "type": "NDC" } ], "description": "INV ASPIRIN/PLACEBO 81 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491322", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-17", "type": "NDC" } ], "description": "INV APIXABAN/PLACEBO 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491323", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-18", "type": "NDC" } ], "description": "INV APIXABAN/PLACEBO 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491324", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "00000-0107-24", "type": "NDC" } ], "description": "INV PREDNISONE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 66 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491325", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2930", "type": "HCPCS" }, { "code": "00000-0107-25", "type": "NDC" } ], "description": "INV METHYLPREDNISOLONE 1000 MG/8 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491327", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-31", "type": "NDC" } ], "description": "INV MEDI-551/PLACEBO 10 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491329", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-32", "type": "NDC" } ], "description": "INV MEDI-551 10 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491331", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1459", "type": "HCPCS" }, { "code": "00000-0107-26", "type": "NDC" } ], "description": "INV IMMUNE GLOBULIN (IGG) (PRIVIGEN) 10%", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491331", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1459", "type": "HCPCS" }, { "code": "00000-0107-27", "type": "NDC" } ], "description": "INV IMMUNE GLOBULIN (IGG) (PRIVIGEN) 10%", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491332", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0610", "type": "HCPCS" }, { "code": "00000-0107-30", "type": "NDC" } ], "description": "INV CALCIUM GLUCONATE 100 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491334", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "P9045", "type": "HCPCS" }, { "code": "00000-0107-28", "type": "NDC" } ], "description": "INV ALBUMIN HUMAN 5% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491334", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "P9045", "type": "HCPCS" }, { "code": "00000-0107-29", "type": "NDC" } ], "description": "INV ALBUMIN HUMAN 5% INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491335", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-34", "type": "NDC" } ], "description": "INV REXLEMESTROCEL-L (CEP-41750)/PLACEBO 37.5 MIL CELLS/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491337", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-43", "type": "NDC" } ], "description": "INV NA-1/PLACEBO 20 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 13.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491339", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-48", "type": "NDC" } ], "description": "INV NIRAPARIB 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 72 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491340", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-50", "type": "NDC" } ], "description": "INV CF-301/PLACEBO 10 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491342", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-20", "type": "NDC" } ], "description": "INV EVEROLIMUS 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491343", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-21", "type": "NDC" } ], "description": "INV EVEROLIMUS 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491344", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-22", "type": "NDC" } ], "description": "INV EVEROLIMUS 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491345", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-60", "type": "NDC" } ], "description": "INV YKP3089 (CENOBAMATE) 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491346", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-61", "type": "NDC" } ], "description": "INV YKP3089 (CENOBAMATE) 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491347", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9022", "type": "HCPCS" }, { "code": "00000-0107-62", "type": "NDC" } ], "description": "INV ATEZOLIZUMAB 60 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491349", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-64", "type": "NDC" } ], "description": "INV RUXOLITINIB 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491350", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-69", "type": "NDC" } ], "description": "INV AMANTADINE (ADS-5102) 68.5 MG/137 MG/PLACEBO ER CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491351", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-70", "type": "NDC" } ], "description": "INV AMANTADINE (ADS-5102) 137 MG ER CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491352", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9302", "type": "HCPCS" }, { "code": "00000-0107-72", "type": "NDC" } ], "description": "INV OFATUMUMAB 20 MG/0.4 ML PRE-FILLED SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491353", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9302", "type": "HCPCS" }, { "code": "00000-0107-73", "type": "NDC" } ], "description": "INV OFATUMUMAB 20 MG/0.4 ML AUTO-INJECTOR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491354", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-74", "type": "NDC" } ], "description": "INV NETUPITANT-PALONOSETRON (AKYNZEO) 300-0.5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491355", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-75", "type": "NDC" } ], "description": "INV OLANZAPINE/PLACEBO 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491356", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-76", "type": "NDC" } ], "description": "INV PROCHLORPERAZINE/PLACEBO 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491357", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-77", "type": "NDC" } ], "description": "INV URCC 16070 TAKE HOME KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491358", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-78", "type": "NDC" } ], "description": "INV CLOSTRIDIUM DIFFICILE VACCINE/PLACEBO 200 MCG/0.5 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491361", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0878", "type": "HCPCS" }, { "code": "00000-0107-87", "type": "NDC" } ], "description": "INV DAPTOMYCIN/PLACEBO 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491363", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0107-88", "type": "NDC" } ], "description": "INV AZTREONAM/PLACEBO 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491365", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0681", "type": "HCPCS" }, { "code": "00000-0107-89", "type": "NDC" } ], "description": "INV CEFTOBIPROLE/PLACEBO 500MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491369", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9301", "type": "HCPCS" }, { "code": "00000-0107-90", "type": "NDC" } ], "description": "INV OBINUTUZUMAB 25MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 40 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491371", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "Q9968", "type": "HCPCS" }, { "code": "00000-0108-15", "type": "NDC" } ], "description": "INV METHYLENE BLUE 5MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491372", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-16", "type": "NDC" } ], "description": "INV ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491375", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-21", "type": "NDC" } ], "description": "INV CIPROFLOXACIN 500 MG/AMOXICILLIN-CLAVULANATE 875 MG-125 MG/PLACEBO CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491376", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-22", "type": "NDC" } ], "description": "INV SULOPENEM ETZADROXIL 500 MG & PROBENECID 500MG/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491377", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1335", "type": "HCPCS" }, { "code": "00000-0108-23", "type": "NDC" } ], "description": "INV ERTAPENEM/PLACEBO 1000 MG/10ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491379", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-24", "type": "NDC" } ], "description": "INV SULOPENEM/PLACEBO 1000MG/10ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491381", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-28", "type": "NDC" } ], "description": "INV CIPROFLOXACIN 500 MG/AMOXICILLIN-CLAVULANATE 875 MG-125 MG/PLACEBO AND METRONIDAZOLE 500 MG/PLACEBO CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491382", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2323", "type": "HCPCS" }, { "code": "00000-0108-41", "type": "NDC" } ], "description": "INV NATALIZUMAB 300 MG/15 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491384", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-47", "type": "NDC" } ], "description": "INV RUCAPARIB/PLACEBO 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491385", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-48", "type": "NDC" } ], "description": "INV RUCAPARIB/PLACEBO 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491386", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-49", "type": "NDC" } ], "description": "INV RUCAPARIB/PLACEBO 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491388", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9299", "type": "HCPCS" }, { "code": "00000-0108-50", "type": "NDC" } ], "description": "INV NIVOLUMAB/PLACEBO 10 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491390", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-57", "type": "NDC" } ], "description": "INV CENOBAMATE/PLACEBO 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491392", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-59", "type": "NDC" } ], "description": "INV CENOBAMATE 50 MG/100 MG/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491393", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-60", "type": "NDC" } ], "description": "INV CENOBAMATE/PLACEBO 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491394", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-61", "type": "NDC" } ], "description": "INV CENOBAMATE/PLACEBO 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491395", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-62", "type": "NDC" } ], "description": "INV CENOBAMATE 50 MG/100 MG/PLACEBO TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491397", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9267", "type": "HCPCS" }, { "code": "61703-0342-50", "type": "NDC" } ], "description": "PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS (NOT ROUNDED)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 231.46, "gross_charge": 356.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491400", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0706", "type": "HCPCS" }, { "code": "00000-0108-63", "type": "NDC" } ], "description": "INV CAFFEINE CITRATE 60 MG/3 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491402", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0280", "type": "HCPCS" }, { "code": "00000-0108-65", "type": "NDC" } ], "description": "INV AMINOPHYLLINE 250 MG/10 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491403", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "A9611", "type": "HCPCS" }, { "code": "00000-0108-66", "type": "NDC" } ], "description": "INV FLURPIRIDAZ F-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 14", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491405", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-78", "type": "NDC" } ], "description": "INV SIPONIMOD 0.25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491406", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-79", "type": "NDC" } ], "description": "INV SIPONIMOD 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491407", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-80", "type": "NDC" } ], "description": "INV CIPROFLOXACIN 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491408", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-81", "type": "NDC" } ], "description": "INV PENICILLIN V POTASSIUM 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491409", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1303", "type": "HCPCS" }, { "code": "00000-0108-82", "type": "NDC" } ], "description": "INV RAVULIZUMAB 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491410", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1303", "type": "HCPCS" }, { "code": "00000-0108-83", "type": "NDC" } ], "description": "INV RAVULIZUMAB/PLACEBO 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491414", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-87", "type": "NDC" } ], "description": "INV OPICINUMAB (BIIB003) 200 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491416", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-88", "type": "NDC" } ], "description": "INV PADSEVONIL 25 MG/100 MG/200 MG/PLACEBO TABLET 4-DAY KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491417", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-89", "type": "NDC" } ], "description": "INV PADSEVONIL 25 MG/100 MG/200 MG/PLACEBO TABLET 7-DAY KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 108 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491418", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3101", "type": "HCPCS" }, { "code": "00000-0108-92", "type": "NDC" } ], "description": "INV TENECTEPLASE/PLACEBO 5 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491419", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9999", "type": "HCPCS" }, { "code": "00000-0108-94", "type": "NDC" } ], "description": "INV AGEN2034 50 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491421", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9999", "type": "HCPCS" }, { "code": "00000-0108-95", "type": "NDC" } ], "description": "INV AGEN1884/PLACEBO 50 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491425", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0108-99", "type": "NDC" } ], "description": "INV VENETOCLAX 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491426", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0010-90", "type": "NDC" } ], "description": "INV VENETOCLAX 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491427", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-01", "type": "NDC" } ], "description": "INV VENETOCLAX 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 32 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491430", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9264", "type": "HCPCS" }, { "code": "00000-0109-02", "type": "NDC" } ], "description": "INV NAB-PACLITAXIL (ABRAXANE) INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491430", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9264", "type": "HCPCS" }, { "code": "00000-0109-03", "type": "NDC" } ], "description": "INV NAB-PACLITAXIL (ABRAXANE) INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491431", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9271", "type": "HCPCS" }, { "code": "00000-0109-07", "type": "NDC" } ], "description": "INV PEMBROLIZUMAB/PLACEBO 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491433", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0051-44", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE (NS) 0.9% SLUSH IRRIGATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 209.79, "gross_charge": 322.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491434", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2329", "type": "HCPCS" }, { "code": "00000-0109-09", "type": "NDC" } ], "description": "INV UBLITUXIMAB 25 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491437", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-12", "type": "NDC" } ], "description": "INV SODIUM CHLORIDE 0.9% SOLUTION FLUSH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491438", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-13", "type": "NDC" } ], "description": "INV DEXTROSE 5% SOLUTION FLUSH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491439", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9267", "type": "HCPCS" }, { "code": "61703-0342-50", "type": "NDC" } ], "description": "PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS (NOT ROUNDED)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 231.46, "gross_charge": 356.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491441", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9060", "type": "HCPCS" }, { "code": "63323-0103-65", "type": "NDC" } ], "description": "CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION (RESEARCH TRIAL ROUNDING TO 1 MG)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 143.78, "gross_charge": 221.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491443", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9181", "type": "HCPCS" }, { "code": "00143-9511-01", "type": "NDC" } ], "description": "ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION (RESEARCH TRIAL ROUNDING TO 1 MG)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 113.52, "gross_charge": 174.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491443", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9181", "type": "HCPCS" }, { "code": "16729-0262-31", "type": "NDC" } ], "description": "ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION (RESEARCH TRIAL ROUNDING TO 1 MG)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 67.14, "gross_charge": 103.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491445", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9040", "type": "HCPCS" }, { "code": "63323-0136-10", "type": "NDC" } ], "description": "BLEOMYCIN 15 UNIT/ML (IM/SC CONCENTRATION)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 125.48, "gross_charge": 193.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491446", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-17", "type": "NDC" } ], "description": "INV OLAPARIB/PLACEBO 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491447", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-18", "type": "NDC" } ], "description": "INV OLAPARIB/PLACEBO 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491448", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-24", "type": "NDC" } ], "description": "INV SATRALIZUMAB 120 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491449", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-27", "type": "NDC" } ], "description": "INV REMDESIVIR 100 MG/20 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491456", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-37", "type": "NDC" } ], "description": "INV MAS825/PLACEBO 100 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491458", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0003-32", "type": "NDC" } ], "description": "INV DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491459", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-38", "type": "NDC" } ], "description": "INV REMDESIVIR 5 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491461", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3262", "type": "HCPCS" }, { "code": "00000-0109-39", "type": "NDC" } ], "description": "INV TOCILIZUMAB/PLACEBO 20MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491463", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-41", "type": "NDC" } ], "description": "INV TL-895/PLACEBO 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491464", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-42", "type": "NDC" } ], "description": "INV TL-895 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491465", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-46", "type": "NDC" } ], "description": "INV REGN10933 + INV REGN10987 2.4 GM/8 GM/PLACEBO IN 0.9% SODIUM CHLORIDE 250 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491466", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9173", "type": "HCPCS" }, { "code": "00000-0109-49", "type": "NDC" } ], "description": "INV DURVALUMAB/PLACEBO 50 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491469", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-53", "type": "NDC" } ], "description": "INV EVOBRUTINIB/PLACEBO 45 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491470", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-65", "type": "NDC" } ], "description": "INV SARS-COV-2 HYPERIMMUNE GLOBULIN (HIVIG)/PLACEBO 100 MG/ML IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491471", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9144", "type": "HCPCS" }, { "code": "00000-0109-56", "type": "NDC" } ], "description": "INV DARATUMUMAB-RHUPH20 120 MG-2,000 UNITS/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491472", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9035", "type": "HCPCS" }, { "code": "00000-0010-49", "type": "NDC" } ], "description": "INV BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491474", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2350", "type": "HCPCS" }, { "code": "00000-0109-63", "type": "NDC" } ], "description": "INV OCRELIZUMAB/PLACEBO 30 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491478", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-66", "type": "NDC" } ], "description": "INV TELAGLENASTAT/PLACEBO 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491479", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0109-70", "type": "NDC" } ], "description": "INV TD-0903/PLACEBO NEBULIZER SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491480", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9228", "type": "HCPCS" }, { "code": "00000-0109-78", "type": "NDC" } ], "description": "INV IPILIMUMAB 5 MG/ML INTRAVENOUS SOLUTION (ROUNDED TO 1 MG)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491484", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1569", "type": "HCPCS" }, { "code": "00000-0109-83", "type": "NDC" } ], "description": "INV IMMUNE GLOBULIN (IGG) (GAMMAGARD) 10%", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491489", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "C9399", "type": "HCPCS" }, { "code": "00000-0109-90", "type": "NDC" } ], "description": "INV REMDESIVIR/PLACEBO 5 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491490", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J1745", "type": "HCPCS" }, { "code": "00000-0109-94", "type": "NDC" } ], "description": "INV INFLIXIMAB 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491493", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-05", "type": "NDC" } ], "description": "INV BATIRAXCEPT (AVB-S6-500)/PLACEBO 20 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491496", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-09", "type": "NDC" } ], "description": "INV PATIROMER/PLACEBO 8.4 GRAM PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491497", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-19", "type": "NDC" } ], "description": "INV FENEBRUTINIB/PLACEBO 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491498", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-32", "type": "NDC" } ], "description": "INV CABOZANTINIB 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491499", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-33", "type": "NDC" } ], "description": "INV CABOZANTINIB 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491500", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-30", "type": "NDC" } ], "description": "INV OSIMERTINIB 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491501", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-31", "type": "NDC" } ], "description": "INV OSIMERTINIB 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491505", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0222", "type": "HCPCS" }, { "code": "00000-0110-45", "type": "NDC" } ], "description": "INV PATISIRAN (ALN-TTR02) 2 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491507", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1945", "type": "HCPCS" }, { "code": "00000-0110-46", "type": "NDC" } ], "description": "INV DARATUMUMAB 20 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491510", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-47", "type": "NDC" } ], "description": "INV IXAZOMIB 2.3 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491511", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-48", "type": "NDC" } ], "description": "INV IXAZOMIB 3 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491512", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-49", "type": "NDC" } ], "description": "INV IXAZOMIB 4 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491514", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9359", "type": "HCPCS" }, { "code": "00000-0110-52", "type": "NDC" } ], "description": "INV LONCASTUXIMAB TESIRINE-LPYL (ADCT-402) 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491516", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00000-0110-53", "type": "NDC" } ], "description": "INV DEXAMETHASONE 4 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491517", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00000-0110-54", "type": "NDC" } ], "description": "INV DEXAMETHASONE/PLACEBO 4 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491518", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-58", "type": "NDC" } ], "description": "INV LAU-7B/PLACEBO 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 9 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491519", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0110-60", "type": "NDC" } ], "description": "INV NEMVALEUKIN ALFA (ALKS 4230) 55.6 MCG/ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491520", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0110-61", "type": "NDC" } ], "description": "INV NEMVALEUKIN ALFA (ALKS 4230) 37.7 MCG/ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491524", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "C9399", "type": "HCPCS" }, { "code": "00000-0110-62", "type": "NDC" } ], "description": "INV SATRALIZUMAB 60 MG/0.5 ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491525", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "C9399", "type": "HCPCS" }, { "code": "00000-0110-63", "type": "NDC" } ], "description": "INV SATRALIZUMAB 120 MG/ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491527", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "C9399", "type": "HCPCS" }, { "code": "00000-0110-64", "type": "NDC" } ], "description": "INV SATRALIZUMAB/PLACEBO 120 MG/ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491530", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-71", "type": "NDC" } ], "description": "INV ZN-C3 25 MG TABLETS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 34 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491531", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-72", "type": "NDC" } ], "description": "INV ZN-C3 100 MG TABLETS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 34 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491532", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1323", "type": "HCPCS" }, { "code": "00000-0110-73", "type": "NDC" } ], "description": "INV ELRANATAMAB (PF-06863135) 40 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491533", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-74", "type": "NDC" } ], "description": "INV TECOVIRIMAT 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 42 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491534", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-75", "type": "NDC" } ], "description": "INV CLOFAZIMINE 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491535", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-13", "type": "NDC" } ], "description": "INV LENALIDOMIDE 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491536", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-77", "type": "NDC" } ], "description": "INV IXAZOMIB/PLACEBO 2.3 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491537", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-78", "type": "NDC" } ], "description": "INV IXAZOMIB/PLACEBO 3 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491538", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-79", "type": "NDC" } ], "description": "INV IXAZOMIB/PLACEBO 4 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491539", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-81", "type": "NDC" } ], "description": "INV TERIFLUNOMIDE/PLACEBO 14 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491540", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-84", "type": "NDC" } ], "description": "INV FENEBRUTINIB 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491541", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-92", "type": "NDC" } ], "description": "INV IBERDOMIDE (CC-220) 0.75 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491542", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-93", "type": "NDC" } ], "description": "INV IBERDOMIDE (CC-220) 1 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491543", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-94", "type": "NDC" } ], "description": "INV IBERDOMIDE (CC-220) 1.3 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491544", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0110-95", "type": "NDC" } ], "description": "INV IBERDOMIDE (CC-220) 1.6 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491549", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9358", "type": "HCPCS" }, { "code": "00000-0111-24", "type": "NDC" } ], "description": "INV FAM-TRASTUZUMAB DERUXTECAN-NXKI 20 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491553", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-27", "type": "NDC" } ], "description": "INV FLECAINIDE ACETATE (FLECIH-103)/PLACEBO", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491554", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-29", "type": "NDC" } ], "description": "INV ASUNDEXIAN/PLACEBO 50MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 98 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491556", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "Q5113", "type": "HCPCS" }, { "code": "00000-0111-30", "type": "NDC" } ], "description": "INV TRASTUZUMAB-PKRB 21 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 150 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491557", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9306", "type": "HCPCS" }, { "code": "00000-0111-31", "type": "NDC" } ], "description": "INV PERTUZUMAB 30MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491559", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-32", "type": "NDC" } ], "description": "INV OLPASIRAN (AMG890)/PLACEBO 142 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491560", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-33", "type": "NDC" } ], "description": "INV EVOGLIPTIN (DA-1229) 5 MG/10 MG/PLACEBO", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 210 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491561", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-39", "type": "NDC" } ], "description": "INV VEBRELTINIB (APL-101) 100MG", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491562", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-45", "type": "NDC" } ], "description": "INV TALQUETAMAB (JNJ-64407564) 2 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491563", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-46", "type": "NDC" } ], "description": "INV TALQUETAMAB (JNJ-64407564) 40 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491565", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9331", "type": "HCPCS" }, { "code": "00000-0111-58", "type": "NDC" } ], "description": "INV SIROLIMUS PROTEIN BOUND 5 MG/ML INTRAVENOUS SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491566", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9015", "type": "HCPCS" }, { "code": "00000-0111-65", "type": "NDC" } ], "description": "INV ALDESLEUKIN INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491567", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9185", "type": "HCPCS" }, { "code": "00000-0111-67", "type": "NDC" } ], "description": "INV FLUDARABINE 50MG/2ML INJECTABLE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491568", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "Q5115", "type": "HCPCS" }, { "code": "00000-0111-68", "type": "NDC" } ], "description": "INV RITUXIMAB-ABBS 10MG/ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491568", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "Q5115", "type": "HCPCS" }, { "code": "00000-0111-69", "type": "NDC" } ], "description": "INV RITUXIMAB-ABBS 10MG/ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491571", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-73", "type": "NDC" } ], "description": "INV MEZIGDOMIDE (CC-92480) 0.2 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491572", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-74", "type": "NDC" } ], "description": "INV MEZIGDOMIDE (CC-92480) 0.3 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491573", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-75", "type": "NDC" } ], "description": "INV MEZIGDOMIDE (CC-92480) 0.4 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491574", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-76", "type": "NDC" } ], "description": "INV MEZIGDOMIDE (CC-92480) 0.6 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491575", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-77", "type": "NDC" } ], "description": "INV MEZIGDOMIDE (CC-92480) 0.8 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491576", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-78", "type": "NDC" } ], "description": "INV MEZIGDOMIDE (CC-92480) 1 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 21 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491577", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "j9036", "type": "HCPCS" }, { "code": "00000-0111-79", "type": "NDC" } ], "description": "INV BENDAMUSTINE 2.5 MG/ML POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491585", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0111-84", "type": "NDC" } ], "description": "INV SELINEXOR/PLACEBO 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491586", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "00000-0111-87", "type": "NDC" } ], "description": "INV 3K3A-APC/PLACEBO INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5.4 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491588", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-88", "type": "NDC" } ], "description": "INV IS-001 LYOPHILIZED POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 22 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491589", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-89", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300) 10 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491590", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-91", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300) 20 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491591", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-92", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300) 30 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491592", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-93", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300) 45 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491593", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-94", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300) 60 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491596", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-95", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300)/PLACEBO 10 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491597", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-96", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300)/PLACEBO 20 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491598", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-97", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300)/PLACEBO 30 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491599", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-98", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300)/PLACEBO 45 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491600", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0111-99", "type": "NDC" } ], "description": "INV RUSFERTIDE (PTG-300)/PLACEBO 60 MG/0.5 ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491603", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "00000-0112-07", "type": "NDC" } ], "description": "INV FREXALIMAB/PLACEBO 150 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491605", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-08", "type": "NDC" } ], "description": "INV MILVEXIAN/PLACEBO 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491613", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-17", "type": "NDC" } ], "description": "INV ONDANSETRON 8 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491614", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-18", "type": "NDC" } ], "description": "INV ONDANSETRON/PLACEBO 8 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491615", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-20", "type": "NDC" } ], "description": "INV NAVTEMADLIN 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491616", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-21", "type": "NDC" } ], "description": "INV NAVTEMADLIN 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491617", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-22", "type": "NDC" } ], "description": "INV NAVTEMADLIN/PLACEBO 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491618", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-23", "type": "NDC" } ], "description": "INV NAVTEMADLIN/PLACEBO 60 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491619", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-24", "type": "NDC" } ], "description": "INV LOPERAMIDE 2 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491620", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-25", "type": "NDC" } ], "description": "INV LOPERAMIDE/PLACEBO 2 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 14 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491623", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9321", "type": "HCPCS" }, { "code": "00000-0112-28", "type": "NDC" } ], "description": "INV EPCORITAMAB-BYSP 4 MG/0.8 ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491624", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9321", "type": "HCPCS" }, { "code": "00000-0112-29", "type": "NDC" } ], "description": "INV EPCORITAMAB-BYSP 48 MG/0.8 ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491625", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-30", "type": "NDC" } ], "description": "INV SOTORASIB 120 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491628", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9303", "type": "HCPCS" }, { "code": "00000-0112-31", "type": "NDC" } ], "description": "INV PANITUMUMAB INJECTION 100 MG/5 ML", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491633", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9321", "type": "HCPCS" }, { "code": "00000-0112-33", "type": "NDC" } ], "description": "INV EPCORITAMAB-BYSP 3 MG CHEMO INJECTION (STEP UP DOSE 3)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.6 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491634", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0112-34", "type": "NDC" } ], "description": "INV SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491635", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "Q9966", "type": "HCPCS" }, { "code": "00000-0112-35", "type": "NDC" } ], "description": "INV STABILIZER MIXTURE (PENTAGALLOYL GLUCOSE-IODOMIDOL) INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491637", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-39", "type": "NDC" } ], "description": "INV LOMUSTINE 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491638", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-40", "type": "NDC" } ], "description": "INV LOMUSTINE 40 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491639", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-41", "type": "NDC" } ], "description": "INV LOMUSTINE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491640", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-42", "type": "NDC" } ], "description": "INV BINIMETINIB 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491641", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-43", "type": "NDC" } ], "description": "INV PALBOCICLIB 125 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491642", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-44", "type": "NDC" } ], "description": "INV PALBOCICLIB 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491643", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-45", "type": "NDC" } ], "description": "INV PALBOCICLIB 75 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491645", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9041", "type": "HCPCS" }, { "code": "00000-0112-50", "type": "NDC" } ], "description": "INV BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491646", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9370", "type": "HCPCS" }, { "code": "00000-0112-54", "type": "NDC" } ], "description": "INV VINCRISTINE 1 MG/ML INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491647", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9000", "type": "HCPCS" }, { "code": "00000-0112-56", "type": "NDC" } ], "description": "INV DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 25 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491651", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "00000-0112-57", "type": "NDC" } ], "description": "INV PREDNISONE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491654", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "00000-0112-67", "type": "NDC" } ], "description": "INV PLOZASIRAN (ARO-APOC3)/PLACEBO INJECTION 25MG", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491655", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-66", "type": "NDC" } ], "description": "INV DAROLUTAMIDE 300MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 120 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491657", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0112-95", "type": "NDC" } ], "description": "INV PLASMALYTE-A 1000ML BAG", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491658", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0112-96", "type": "NDC" } ], "description": "INV PLASMALYTE-A 500ML BAG", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491659", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0112-97", "type": "NDC" } ], "description": "INV PLASMALYTE-A 10ML SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491660", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "00000-0112-98", "type": "NDC" } ], "description": "INV OLVIMULOGENE NANIVACIREPVEC (OLVI-VEC) 1.9 X10EXP8 PFU/ML SUSPENSION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15.8 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491662", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9308", "type": "HCPCS" }, { "code": "00000-0113-02", "type": "NDC" } ], "description": "INV RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491666", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J0225", "type": "HCPCS" }, { "code": "00000-0113-13", "type": "NDC" } ], "description": "INV VUTRISIRAN (ALN-TTRSC02) 25 MG/0.5 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491667", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9299", "type": "HCPCS" }, { "code": "00000-0113-16", "type": "NDC" } ], "description": "INV RELATLIMAB (BMS-986016) INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 48 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491669", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "C9399", "type": "HCPCS" }, { "code": "00000-0113-19", "type": "NDC" } ], "description": "INV NTLA-2001/PLACEBO INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 36.6666666666666 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491671", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9999", "type": "HCPCS" }, { "code": "00000-0113-28", "type": "NDC" } ], "description": "INV ABEMACICLIB 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 60 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491672", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9999", "type": "HCPCS" }, { "code": "00000-0113-27", "type": "NDC" } ], "description": "INV ENTRECTINIB 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491674", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J99999", "type": "HCPCS" }, { "code": "00000-0113-26", "type": "NDC" } ], "description": "INV ADAGRASIB 200MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 132 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491675", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9380", "type": "HCPCS" }, { "code": "00000-0113-31", "type": "NDC" } ], "description": "INV TECLISTAMAB (JNJ-64407957) 10 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491676", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9380", "type": "HCPCS" }, { "code": "00000-0113-32", "type": "NDC" } ], "description": "INV TECLISTAMAB (JNJ-64407957) 90 MG/ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.7 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491678", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0113-33", "type": "NDC" } ], "description": "INV QUIZARTINIB DIHYDROCHLORIDE/PLACEBO 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491679", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "25600001", "type": "HCPCS" }, { "code": "00000-0113-34", "type": "NDC" } ], "description": "INV QUIZARTINIB DIHYDROCHLORIDE/PLACEBO 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491680", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9286", "type": "HCPCS" }, { "code": "00000-0113-36", "type": "NDC" } ], "description": "INV GLOFITAMAB (RO7082859) 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491682", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J3590", "type": "HCPCS" }, { "code": "00000-0113-37", "type": "NDC" } ], "description": "INV ENGLUMAFUSP ALFA (RO7227166) 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491690", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J1100", "type": "HCPCS" }, { "code": "00000-0113-43", "type": "NDC" } ], "description": "INV DEXAMETHASONE 8 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491693", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9032", "type": "HCPCS" }, { "code": "00000-0113-46", "type": "NDC" } ], "description": "INV BELINOSTAT 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ME", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491694", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J9307", "type": "HCPCS" }, { "code": "00000-0113-45", "type": "NDC" } ], "description": "INV PRALATREXATE 20 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-491695", "type": "CDM" }, { "code": "256", "type": "RC" }, { "code": "J2351", "type": "HCPCS" }, { "code": "00000-0113-47", "type": "NDC" } ], "description": "INV OCRELIZUMAB 920 MG-HYALURONIDASE-OCSQ 23000 UNIT/23 ML SUBCUT SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 23 ML", "billing_class": "facility", "discounted_cash": 0.42, "gross_charge": 0.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4952", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68094-0031-62", "type": "NDC" } ], "description": "METHADONE 5 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 10.4, "gross_charge": 16.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4954", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-5755-62", "type": "NDC" } ], "description": "METHADONE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.24, "gross_charge": 9.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4961", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0240-01", "type": "NDC" } ], "description": "METHAZOLAMIDE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.62, "gross_charge": 7.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4962", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62559-0241-01", "type": "NDC" } ], "description": "METHAZOLAMIDE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.64, "gross_charge": 11.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4970", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2800", "type": "HCPCS" }, { "code": "55150-0223-10", "type": "NDC" } ], "description": "METHOCARBAMOL 100 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 26.52, "gross_charge": 40.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4971", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0559-01", "type": "NDC" } ], "description": "METHOCARBAMOL 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4972", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0568-01", "type": "NDC" } ], "description": "METHOCARBAMOL 750 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4973", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8610", "type": "HCPCS" }, { "code": "00904-7141-10", "type": "NDC" } ], "description": "METHOTREXATE SODIUM 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.96, "gross_charge": 10.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4974", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9260", "type": "HCPCS" }, { "code": "61703-0350-38", "type": "NDC" } ], "description": "METHOTREXATE SODIUM 25 MG/ML INJECTION FOR ECTOPIC PREGNANCY (SORD)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 56.65, "gross_charge": 87.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4986", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0823-21", "type": "NDC" } ], "description": "METHYLPHENIDATE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.52, "gross_charge": 13.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4988", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0805-11", "type": "NDC" } ], "description": "METHYLPHENIDATE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.98, "gross_charge": 15.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4992", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7509", "type": "HCPCS" }, { "code": "59746-0003-14", "type": "NDC" } ], "description": "METHYLPREDNISOLONE 16 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.67, "gross_charge": 11.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4993", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7509", "type": "HCPCS" }, { "code": "68084-0149-01", "type": "NDC" } ], "description": "METHYLPREDNISOLONE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.07, "gross_charge": 7.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4995", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1010", "type": "HCPCS" }, { "code": "00009-0280-02", "type": "NDC" } ], "description": "METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 28.83, "gross_charge": 44.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-4996", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1010", "type": "HCPCS" }, { "code": "70121-1552-01", "type": "NDC" } ], "description": "METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 40.46, "gross_charge": 62.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5002", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2765", "type": "HCPCS" }, { "code": "00703-4502-91", "type": "NDC" } ], "description": "METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.62, "gross_charge": 34.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5006", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0620-01", "type": "NDC" } ], "description": "METOCLOPRAMIDE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5007", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0616", "type": "HCPCS" }, { "code": "00409-2016-10", "type": "NDC" } ], "description": "METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 23.24, "gross_charge": 35.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5008", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62584-0267-01", "type": "NDC" } ], "description": "METOPROLOL TARTRATE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5009", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62584-0266-01", "type": "NDC" } ], "description": "METOPROLOL TARTRATE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5016", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0550-01", "type": "NDC" } ], "description": "METRONIDAZOLE 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5018", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1836", "type": "HCPCS" }, { "code": "00338-1055-48", "type": "NDC" } ], "description": "METRONIDAZOLE 5 MG/ML IVPB", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 40.4, "gross_charge": 62.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5039", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51672-2001-02", "type": "NDC" } ], "description": "MICONAZOLE NITRATE 2 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 2.6, "gross_charge": 4.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5040", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7734-45", "type": "NDC" } ], "description": "MICONAZOLE NITRATE 2 % VAGINAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 45 GR", "billing_class": "facility", "discounted_cash": 16.28, "gross_charge": 25.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5086", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "48433-0202-30", "type": "NDC" } ], "description": "MINERAL OIL ORAL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 0.62, "gross_charge": 0.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5087", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00132-0301-40", "type": "NDC" } ], "description": "MINERAL OIL ENEMA", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 133 ML", "billing_class": "facility", "discounted_cash": 6.79, "gross_charge": 10.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5111", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65862-0209-01", "type": "NDC" } ], "description": "MINOCYCLINE 50 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5114", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49884-0257-01", "type": "NDC" } ], "description": "MINOXIDIL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5115", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0204-01", "type": "NDC" } ], "description": "MINOXIDIL 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5170", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2272", "type": "HCPCS" }, { "code": "76045-0004-01", "type": "NDC" } ], "description": "MORPHINE 2 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 28.89, "gross_charge": 44.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5172", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2272", "type": "HCPCS" }, { "code": "76045-0005-10", "type": "NDC" } ], "description": "MORPHINE 4 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 23.92, "gross_charge": 36.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5176", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68094-0001-59", "type": "NDC" } ], "description": "MORPHINE 10 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 8.74, "gross_charge": 13.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5178", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-0235-24", "type": "NDC" } ], "description": "MORPHINE 15 MG IMMEDIATE RELEASE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.25, "gross_charge": 11.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5179", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-0236-24", "type": "NDC" } ], "description": "MORPHINE 30 MG IMMEDIATE RELEASE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.58, "gross_charge": 13.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5335", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2290", "type": "HCPCS" }, { "code": "55150-0123-16", "type": "NDC" } ], "description": "NAFCILLIN 2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 30.16, "gross_charge": 46.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5339", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2300", "type": "HCPCS" }, { "code": "00409-1463-49", "type": "NDC" } ], "description": "NALBUPHINE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 31.69, "gross_charge": 48.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5340", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2300", "type": "HCPCS" }, { "code": "00409-1467-01", "type": "NDC" } ], "description": "NALBUPHINE 20 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 35.1, "gross_charge": 54.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5373", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2312", "type": "HCPCS" }, { "code": "67457-0299-00", "type": "NDC" } ], "description": "NALOXONE 0.4 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 141.67, "gross_charge": 217.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5374", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2312", "type": "HCPCS" }, { "code": "76329-3369-01", "type": "NDC" } ], "description": "NALOXONE 1 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 84.7, "gross_charge": 130.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5391", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0594-11", "type": "NDC" } ], "description": "NAPROXEN 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5392", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0595-11", "type": "NDC" } ], "description": "NAPROXEN 375 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5393", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0491-01", "type": "NDC" } ], "description": "NAPROXEN 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5474", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0790-62", "type": "NDC" } ], "description": "NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 133.54, "gross_charge": 205.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5539", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0582-11", "type": "NDC" } ], "description": "NIACIN 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5542", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-2272-60", "type": "NDC" } ], "description": "NIACIN 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.06, "gross_charge": 4.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5545", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0583-11", "type": "NDC" } ], "description": "NIACIN ER 500 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.2, "gross_charge": 0.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5558", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69315-0211-01", "type": "NDC" } ], "description": "NIFEDIPINE 10 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5559", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69315-0212-01", "type": "NDC" } ], "description": "NIFEDIPINE 20 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5599", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2305", "type": "HCPCS" }, { "code": "00517-4810-25", "type": "NDC" } ], "description": "NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 61.26, "gross_charge": 94.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5600", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49483-0221-10", "type": "NDC" } ], "description": "NITROGLYCERIN ER 2.5 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.7, "gross_charge": 5.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5601", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49483-0222-10", "type": "NDC" } ], "description": "NITROGLYCERIN ER 6.5 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5604", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43598-0436-11", "type": "NDC" } ], "description": "NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 42.77, "gross_charge": 65.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5606", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00281-0326-08", "type": "NDC" } ], "description": "NITROGLYCERIN 2 % TRANSDERMAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 GR", "billing_class": "facility", "discounted_cash": 7.15, "gross_charge": 11.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5749", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00713-0678-15", "type": "NDC" } ], "description": "NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 17.48, "gross_charge": 26.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5750", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "72578-0089-01", "type": "NDC" } ], "description": "NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 17.91, "gross_charge": 27.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5752", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-0983-01", "type": "NDC" } ], "description": "NYSTATIN 500,000 UNIT TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.88, "gross_charge": 7.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5754", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0880-14", "type": "NDC" } ], "description": "NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 17.16, "gross_charge": 26.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5886", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2360", "type": "HCPCS" }, { "code": "25021-0651-02", "type": "NDC" } ], "description": "ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 54.54, "gross_charge": 83.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5940", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00406-0512-01", "type": "NDC" } ], "description": "OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.78, "gross_charge": 8.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5943", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0410-59", "type": "NDC" } ], "description": "OXYMETAZOLINE 0.05 % NASAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 10.92, "gross_charge": 16.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-5944", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2590", "type": "HCPCS" }, { "code": "63323-0012-07", "type": "NDC" } ], "description": "OXYTOCIN 10 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 22.3, "gross_charge": 34.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6030", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2440", "type": "HCPCS" }, { "code": "00517-4002-25", "type": "NDC" } ], "description": "PAPAVERINE 30 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 71.5, "gross_charge": 110.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6085", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" }, { "code": "00049-0530-22", "type": "NDC" } ], "description": "PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 101.34, "gross_charge": 155.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6086", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2540", "type": "HCPCS" }, { "code": "00049-0520-22", "type": "NDC" } ], "description": "PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 36.04, "gross_charge": 55.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6091", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-4127-73", "type": "NDC" } ], "description": "PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 19.73, "gross_charge": 30.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6092", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00143-9837-01", "type": "NDC" } ], "description": "PENICILLIN V POTASSIUM 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6097", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2515", "type": "HCPCS" }, { "code": "25021-0676-20", "type": "NDC" } ], "description": "PENTOBARBITAL SODIUM 50 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 360.1, "gross_charge": 554.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6158", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0602-01", "type": "NDC" } ], "description": "PERPHENAZINE 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.65, "gross_charge": 7.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6212", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00603-1508-05", "type": "NDC" } ], "description": "PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 9.91, "gross_charge": 15.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6217", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16571-0673-01", "type": "NDC" } ], "description": "PHENOBARBITAL 32.4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.72, "gross_charge": 8.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6220", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "75826-0142-10", "type": "NDC" } ], "description": "PHENOBARBITAL 97.2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6221", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2560", "type": "HCPCS" }, { "code": "00641-0477-21", "type": "NDC" } ], "description": "PHENOBARBITAL SODIUM 130 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.769230769230769 ML", "billing_class": "facility", "discounted_cash": 116.25, "gross_charge": 178.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6224", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2560", "type": "HCPCS" }, { "code": "42494-0441-01", "type": "NDC" } ], "description": "PHENOBARBITAL SODIUM 65 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 56.0, "gross_charge": 86.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6242", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2371", "type": "HCPCS" }, { "code": "72485-0505-01", "type": "NDC" } ], "description": "PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.01 ML", "billing_class": "facility", "discounted_cash": 21.42, "gross_charge": 32.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6244", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00225-0805-47", "type": "NDC" } ], "description": "PHENYLEPHRINE 0.5 % NASAL SPRAY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 14.3, "gross_charge": 22.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6256", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1165", "type": "HCPCS" }, { "code": "00641-6139-10", "type": "NDC" } ], "description": "PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 23.37, "gross_charge": 35.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6279", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0203-15", "type": "NDC" } ], "description": "PILOCARPINE 1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 203.16, "gross_charge": 312.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6280", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70069-0191-01", "type": "NDC" } ], "description": "PILOCARPINE 2 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 88.34, "gross_charge": 135.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6282", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70069-0201-01", "type": "NDC" } ], "description": "PILOCARPINE 4 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 90.84, "gross_charge": 139.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6393", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "55150-0234-10", "type": "NDC" } ], "description": "POLYMYXIN B SULFATE 500,000 UNIT/2 ML SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.95, "gross_charge": 49.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6420", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-8183-25", "type": "NDC" } ], "description": "POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 30.97, "gross_charge": 47.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6423", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51801-0001-40", "type": "NDC" } ], "description": "POTASSIUM BICARBONATE-CITRIC ACID 25 MEQ EFFERVESCENT TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6429", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "63323-0965-01", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 29.58, "gross_charge": 45.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6432", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "81033-0220-15", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 7.31, "gross_charge": 11.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6445", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "75834-0280-30", "type": "NDC" } ], "description": "POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 12.42, "gross_charge": 19.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6451", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00517-2102-25", "type": "NDC" } ], "description": "POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 53.04, "gross_charge": 81.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6462", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2730", "type": "HCPCS" }, { "code": "60977-0141-27", "type": "NDC" } ], "description": "PRALIDOXIME 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1589.22, "gross_charge": 2444.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6468", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0996-01", "type": "NDC" } ], "description": "PRAZOSIN 1 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6469", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0997-01", "type": "NDC" } ], "description": "PRAZOSIN 2 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.75, "gross_charge": 8.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6470", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0632-01", "type": "NDC" } ], "description": "PRAZOSIN 5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.59, "gross_charge": 14.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6487", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0637-05", "type": "NDC" } ], "description": "PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 74.33, "gross_charge": 114.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6492", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "00054-3722-50", "type": "NDC" } ], "description": "PREDNISONE 5 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 7.12, "gross_charge": 10.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6493", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "62135-0470-90", "type": "NDC" } ], "description": "PREDNISONE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.64, "gross_charge": 13.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6494", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "60687-0134-01", "type": "NDC" } ], "description": "PREDNISONE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6495", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "00054-8740-25", "type": "NDC" } ], "description": "PREDNISONE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6496", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "60687-0145-01", "type": "NDC" } ], "description": "PREDNISONE 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6497", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "60687-0122-01", "type": "NDC" } ], "description": "PREDNISONE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6498", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7512", "type": "HCPCS" }, { "code": "60687-0854-11", "type": "NDC" } ], "description": "PREDNISONE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-654", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "67457-0118-50", "type": "NDC" } ], "description": "ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.2 ML", "billing_class": "facility", "discounted_cash": 22.52, "gross_charge": 34.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6541", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "76385-0102-01", "type": "NDC" } ], "description": "PRIMAQUINE 26.3 MG (15 MG BASE) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.52, "gross_charge": 8.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6544", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0203-11", "type": "NDC" } ], "description": "PRIMIDONE 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.16, "gross_charge": 6.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6561", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00527-1367-01", "type": "NDC" } ], "description": "PROBENECID 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.79, "gross_charge": 10.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6562", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2690", "type": "HCPCS" }, { "code": "00409-1902-11", "type": "NDC" } ], "description": "PROCAINAMIDE 100 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 144.07, "gross_charge": 221.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6580", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0780", "type": "HCPCS" }, { "code": "25021-0790-02", "type": "NDC" } ], "description": "PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 22.68, "gross_charge": 34.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6582", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59746-0115-06", "type": "NDC" } ], "description": "PROCHLORPERAZINE MALEATE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6583", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0814-65", "type": "NDC" } ], "description": "PROCHLORPERAZINE MALEATE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.78, "gross_charge": 7.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6597", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2675", "type": "HCPCS" }, { "code": "00517-0750-01", "type": "NDC" } ], "description": "PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 21.84, "gross_charge": 33.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6620", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00116-4023-16", "type": "NDC" } ], "description": "PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6622", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0155-01", "type": "NDC" } ], "description": "PROMETHAZINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6624", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00713-0132-06", "type": "NDC" } ], "description": "PROMETHAZINE 50 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 53.36, "gross_charge": 82.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-663", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0860-11", "type": "NDC" } ], "description": "ASCORBIC ACID (VITAMIN C) 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-664", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-0523-61", "type": "NDC" } ], "description": "ASCORBIC ACID (VITAMIN C) 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6644", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0016-01", "type": "NDC" } ], "description": "PROPARACAINE 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 85.96, "gross_charge": 132.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6656", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0587-01", "type": "NDC" } ], "description": "PROPRANOLOL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6657", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69238-2078-01", "type": "NDC" } ], "description": "PROPRANOLOL 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6662", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0964-95", "type": "NDC" } ], "description": "PROPYLTHIOURACIL 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.48, "gross_charge": 11.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6677", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2720", "type": "HCPCS" }, { "code": "63323-0229-35", "type": "NDC" } ], "description": "PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 25.35, "gross_charge": 39.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6714", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6990-61", "type": "NDC" } ], "description": "PSEUDOEPHEDRINE 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6716", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0107-52", "type": "NDC" } ], "description": "PSEUDOEPHEDRINE ER 120 MG TABLET,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.2, "gross_charge": 0.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6738", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70954-0484-20", "type": "NDC" } ], "description": "PYRAZINAMIDE 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11.5, "gross_charge": 17.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6744", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3415", "type": "HCPCS" }, { "code": "63323-0180-01", "type": "NDC" } ], "description": "PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 25.06, "gross_charge": 38.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6748", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0858-15", "type": "NDC" } ], "description": "PYRIDOXINE (VITAMIN B6) 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-6777", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42806-0513-30", "type": "NDC" } ], "description": "QUINIDINE SULFATE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.68, "gross_charge": 39.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-679", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "63739-0434-02", "type": "NDC" } ], "description": "ASPIRIN 81 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-681", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "66553-0001-01", "type": "NDC" } ], "description": "ASPIRIN 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-685", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57896-0921-10", "type": "NDC" } ], "description": "ASPIRIN 325 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-688", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57896-0981-10", "type": "NDC" } ], "description": "ASPIRIN 81 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-693", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00574-7034-12", "type": "NDC" } ], "description": "ASPIRIN 300 MG RECTAL SUPPOSITORY", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.72, "gross_charge": 1.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70255", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "78112-0736-45", "type": "NDC" } ], "description": "POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 2.34, "gross_charge": 3.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70267", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9261", "type": "HCPCS" }, { "code": "70710-1726-01", "type": "NDC" } ], "description": "NELARABINE 250 MG/50 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 409.18, "gross_charge": 629.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7028", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-1966-07", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 21.71, "gross_charge": 33.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70284", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60258-0006-01", "type": "NDC" } ], "description": "POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.03, "gross_charge": 6.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70287", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0129", "type": "HCPCS" }, { "code": "00003-2187-13", "type": "NDC" } ], "description": "ABATACEPT (WITH MALTOSE) 250 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4934.18, "gross_charge": 7591.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70306", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0157-21", "type": "NDC" } ], "description": "ARIPIPRAZOLE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.36, "gross_charge": 6.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7034", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65162-0512-10", "type": "NDC" } ], "description": "SALSALATE 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70397", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0338-11", "type": "NDC" } ], "description": "QUETIAPINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70404", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7187", "type": "HCPCS" }, { "code": "63833-0615-02", "type": "NDC" } ], "description": "ANTIHEMOPHILIC FACTOR-VWF 250 UNIT-600 UNIT IV KIT (FVIII UNITS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1962.32, "gross_charge": 3018.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70405", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7187", "type": "HCPCS" }, { "code": "63833-0616-02", "type": "NDC" } ], "description": "ANTIHEMOPHILIC FACTOR-VWF 500 UNIT-1,200 UNIT IV KIT (FVIII UNIITS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3871.27, "gross_charge": 5955.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70406", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7187", "type": "HCPCS" }, { "code": "63833-0617-02", "type": "NDC" } ], "description": "ANTIHEMOPHILIC FACTOR-VWF 1,000 UNIT-2,400 UNIT IV KIT (FVIII UNITS)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7689.18, "gross_charge": 11829.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70434", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0549-21", "type": "NDC" } ], "description": "RANOLAZINE ER 500 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.17, "gross_charge": 7.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70472", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00254-3029-02", "type": "NDC" } ], "description": "LUBIPROSTONE 24 MCG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.71, "gross_charge": 7.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70536", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-0829-01", "type": "NDC" } ], "description": "FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 16 GR", "billing_class": "facility", "discounted_cash": 27.27, "gross_charge": 41.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70545", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "42023-0105-01", "type": "NDC" } ], "description": "METHOHEXITAL 500 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 358.48, "gross_charge": 551.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-70838", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6765-20", "type": "NDC" } ], "description": "CETIRIZINE 1 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-716", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0685-01", "type": "NDC" } ], "description": "ATENOLOL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.41, "gross_charge": 5.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-717", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0605-01", "type": "NDC" } ], "description": "ATENOLOL 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.32, "gross_charge": 5.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-718", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0684-20", "type": "NDC" } ], "description": "ATENOLOL 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7224", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "67877-0124-05", "type": "NDC" } ], "description": "SILVER SULFADIAZINE 1 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 GR", "billing_class": "facility", "discounted_cash": 31.33, "gross_charge": 48.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7226", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1223-08", "type": "NDC" } ], "description": "SIMETHICONE 125 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7227", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24385-0118-78", "type": "NDC" } ], "description": "SIMETHICONE 80 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7228", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-5894-62", "type": "NDC" } ], "description": "SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7228", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0547-03", "type": "NDC" } ], "description": "SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7228", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "19903-0010-21", "type": "NDC" } ], "description": "SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 2.73, "gross_charge": 4.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7242", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0937-47", "type": "NDC" } ], "description": "SIMPLE SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 40.4, "gross_charge": 62.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-730", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0461", "type": "HCPCS" }, { "code": "64253-0400-91", "type": "NDC" } ], "description": "ATROPINE 0.1 MG/ML INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 24.05, "gross_charge": 37.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7301", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00409-7299-45", "type": "NDC" } ], "description": "SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 30.52, "gross_charge": 46.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7310", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "62991-1701-02", "type": "NDC" } ], "description": "SODIUM BICARBONATE (BULK) POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2500 GR", "billing_class": "facility", "discounted_cash": 128.15, "gross_charge": 197.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7311", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00536-1046-10", "type": "NDC" } ], "description": "SODIUM BICARBONATE 325 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7318", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0043-04", "type": "NDC" } ], "description": "SODIUM CHLORIDE 0.45 % IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7321", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7131", "type": "HCPCS" }, { "code": "00338-0054-03", "type": "NDC" } ], "description": "SODIUM CHLORIDE 3 % HYPEROSMOLAR INTRAVENOUS INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 45.01, "gross_charge": 69.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7322", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7131", "type": "HCPCS" }, { "code": "63323-0093-01", "type": "NDC" } ], "description": "SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 40.56, "gross_charge": 62.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-734", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0462", "type": "HCPCS" }, { "code": "00517-1001-01", "type": "NDC" } ], "description": "ATROPINE 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 32.66, "gross_charge": 50.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7351", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "63323-0881-16", "type": "NDC" } ], "description": "SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 52.16, "gross_charge": 80.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7356", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "10702-0036-45", "type": "NDC" } ], "description": "SODIUM POLYSTYRENE SULFONATE 15 GRAM ORAL POWDER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 454 GR", "billing_class": "facility", "discounted_cash": 131.82, "gross_charge": 202.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7359", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0670-04", "type": "NDC" } ], "description": "SULFACETAMIDE SODIUM 10 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 102.67, "gross_charge": 157.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-736", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-6226-02", "type": "NDC" } ], "description": "ATROPINE 1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 182.32, "gross_charge": 280.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7364", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0209", "type": "HCPCS" }, { "code": "60267-0705-50", "type": "NDC" } ], "description": "SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 345.74, "gross_charge": 531.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7413", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46287-0500-30", "type": "NDC" } ], "description": "SORBITOL 70 % SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 5.1, "gross_charge": 7.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7415", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0295-47", "type": "NDC" } ], "description": "SORBITOL 3 % IRRIGATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3000 ML", "billing_class": "facility", "discounted_cash": 70.88, "gross_charge": 109.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7437", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0465-01", "type": "NDC" } ], "description": "SPIRONOLACTONE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7485", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0003-47", "type": "NDC" } ], "description": "WATER FOR IRRIGATION, STERILE SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 42.28, "gross_charge": 65.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7485", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0004-02", "type": "NDC" } ], "description": "WATER FOR IRRIGATION, STERILE SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 50.47, "gross_charge": 77.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7485", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0004-03", "type": "NDC" } ], "description": "WATER FOR IRRIGATION, STERILE SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7536", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0330", "type": "HCPCS" }, { "code": "25021-0677-10", "type": "NDC" } ], "description": "SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.36, "gross_charge": 34.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7554", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42806-0757-60", "type": "NDC" } ], "description": "SULFADIAZINE 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 31.1, "gross_charge": 47.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7555", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0614-11", "type": "NDC" } ], "description": "SULFAMETHOXAZOLE 800 MG-TRIMETHOPRIM 160 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7556", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2865", "type": "HCPCS" }, { "code": "00703-9514-03", "type": "NDC" } ], "description": "SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 59.22, "gross_charge": 91.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7562", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59762-5000-05", "type": "NDC" } ], "description": "SULFASALAZINE 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7563", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59762-0104-06", "type": "NDC" } ], "description": "SULFASALAZINE 500 MG TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76334", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0881", "type": "HCPCS" }, { "code": "55513-0032-01", "type": "NDC" } ], "description": "DARBEPOETIN ALFA 500 MCG/ML IN POLYSORBATE INJECTION SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 3696.48, "gross_charge": 5686.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76335", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "54629-4097-60", "type": "NDC" } ], "description": "ACETYLCYSTEINE 600 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76338", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3473", "type": "HCPCS" }, { "code": "18657-0117-04", "type": "NDC" } ], "description": "HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 176.15, "gross_charge": 271.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76364", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0894", "type": "HCPCS" }, { "code": "55111-0556-10", "type": "NDC" } ], "description": "DECITABINE 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 241.31, "gross_charge": 371.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76444", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-4765-05", "type": "NDC" } ], "description": "VARENICLINE TARTRATE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.42, "gross_charge": 26.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76445", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-4766-06", "type": "NDC" } ], "description": "VARENICLINE TARTRATE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17.42, "gross_charge": 26.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76480", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-3060-56", "type": "NDC" } ], "description": "RASAGILINE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.92, "gross_charge": 10.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76527", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2315", "type": "HCPCS" }, { "code": "65757-0300-01", "type": "NDC" } ], "description": "NALTREXONE ER 380 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5379.01, "gross_charge": 8275.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76677", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64896-0695-13", "type": "NDC" } ], "description": "OXYMORPHONE ER 5 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.56, "gross_charge": 28.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76679", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "64896-0699-13", "type": "NDC" } ], "description": "OXYMORPHONE ER 20 MG TABLET,EXTENDED RELEASE,12 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 50.34, "gross_charge": 77.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76717", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3628-06", "type": "NDC" } ], "description": "DASATINIB 20 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 48.91, "gross_charge": 75.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76718", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3629-06", "type": "NDC" } ], "description": "DASATINIB 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 103.87, "gross_charge": 159.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76719", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3630-06", "type": "NDC" } ], "description": "DASATINIB 70 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 132.37, "gross_charge": 203.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76720", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00436-0672-16", "type": "NDC" } ], "description": "SODIUM HYPOCHLORITE 0.125 % SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 40.4, "gross_charge": 62.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76822", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62332-0103-30", "type": "NDC" } ], "description": "ARIPIPRAZOLE 10 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.38, "gross_charge": 19.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76823", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43598-0734-30", "type": "NDC" } ], "description": "ARIPIPRAZOLE 15 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.38, "gross_charge": 19.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76824", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69339-0160-19", "type": "NDC" } ], "description": "MEGESTROL 400 MG/10 ML (10 ML) ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 5.95, "gross_charge": 9.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76843", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J8501", "type": "HCPCS" }, { "code": "00781-2321-51", "type": "NDC" } ], "description": "APREPITANT 40 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 82.71, "gross_charge": 127.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76868", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2783", "type": "HCPCS" }, { "code": "00024-5151-75", "type": "NDC" } ], "description": "RASBURICASE 7.5 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17972.63, "gross_charge": 27650.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76950", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "20555-0033-00", "type": "NDC" } ], "description": "CHOLECALCIFEROL (VITAMIN D3) 25 MCG (1,000 UNIT) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76966", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0881", "type": "HCPCS" }, { "code": "55513-0006-01", "type": "NDC" } ], "description": "DARBEPOETIN ALFA 200 MCG/ML IN POLYSORBATE INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.3 ML", "billing_class": "facility", "discounted_cash": 1491.42, "gross_charge": 2294.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-76988", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16729-0182-17", "type": "NDC" } ], "description": "HYDROCHLOROTHIAZIDE 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.09, "gross_charge": 4.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77009", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2274", "type": "HCPCS" }, { "code": "00641-6039-01", "type": "NDC" } ], "description": "MORPHINE (PF) 10 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 642.07, "gross_charge": 987.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77012", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7307", "type": "HCPCS" }, { "code": "78206-0145-01", "type": "NDC" } ], "description": "ETONOGESTREL 68 MG SUBDERMAL IMPLANT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2126.31, "gross_charge": 3271.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7711", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59651-0299-60", "type": "NDC" } ], "description": "TAMOXIFEN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77195", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1953", "type": "HCPCS" }, { "code": "00409-2011-25", "type": "NDC" } ], "description": "LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 25.38, "gross_charge": 39.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77308", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00517-6510-25", "type": "NDC" } ], "description": "SELENIUM 40 MCG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 66.07, "gross_charge": 101.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77371", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00254-1016-36", "type": "NDC" } ], "description": "POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 73.71, "gross_charge": 113.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7753", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0779-15", "type": "NDC" } ], "description": "TEMAZEPAM 15 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77615", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00006-0221-01", "type": "NDC" } ], "description": "SITAGLIPTIN PHOSPHATE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.66, "gross_charge": 36.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77616", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00006-0112-28", "type": "NDC" } ], "description": "SITAGLIPTIN PHOSPHATE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.66, "gross_charge": 36.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77617", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00006-0277-01", "type": "NDC" } ], "description": "SITAGLIPTIN PHOSPHATE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.66, "gross_charge": 36.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77648", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-5528-56", "type": "NDC" } ], "description": "ATAZANAVIR 300 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 22.78, "gross_charge": 35.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77685", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2248", "type": "HCPCS" }, { "code": "63323-0729-10", "type": "NDC" } ], "description": "MICAFUNGIN 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 91.1, "gross_charge": 140.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-77725", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1576-10", "type": "NDC" } ], "description": "METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 9.0, "gross_charge": 13.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7783", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1071", "type": "HCPCS" }, { "code": "00009-0347-02", "type": "NDC" } ], "description": "TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 35.2, "gross_charge": 54.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7784", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1071", "type": "HCPCS" }, { "code": "00009-0086-01", "type": "NDC" } ], "description": "TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 27.33, "gross_charge": 42.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7800", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69968-0355-01", "type": "NDC" } ], "description": "TETRAHYDROZOLINE 0.05 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 2.54, "gross_charge": 3.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-78003", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-1775-05", "type": "NDC" } ], "description": "CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 9.2, "gross_charge": 14.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-78064", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0459-01", "type": "NDC" } ], "description": "PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 20.12, "gross_charge": 30.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-78065", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0470-01", "type": "NDC" } ], "description": "PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 20.12, "gross_charge": 30.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7821", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "27808-0033-01", "type": "NDC" } ], "description": "THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 18.75 ML", "billing_class": "facility", "discounted_cash": 6.7, "gross_charge": 10.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-78310", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0397-25", "type": "NDC" } ], "description": "MESALAMINE 1.2 GRAM TABLET,DELAYED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 18.95, "gross_charge": 29.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-78653", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70839-0150-30", "type": "NDC" } ], "description": "ALISKIREN 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.64, "gross_charge": 37.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7876", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3411", "type": "HCPCS" }, { "code": "63323-0013-09", "type": "NDC" } ], "description": "THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 23.98, "gross_charge": 36.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7877", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7191-06", "type": "NDC" } ], "description": "THIAMINE HCL (VITAMIN B1) 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7894", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0565-01", "type": "NDC" } ], "description": "THIORIDAZINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7899", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0566-01", "type": "NDC" } ], "description": "THIORIDAZINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7901", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9340", "type": "HCPCS" }, { "code": "00143-9309-01", "type": "NDC" } ], "description": "THIOTEPA 15 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1056.02, "gross_charge": 1624.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7906", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70954-0016-10", "type": "NDC" } ], "description": "THIOTHIXENE 5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.46, "gross_charge": 8.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-7995", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70069-0131-01", "type": "NDC" } ], "description": "TOBRAMYCIN 0.3 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 18.04, "gross_charge": 27.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8083", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0454-01", "type": "NDC" } ], "description": "TRAZODONE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8084", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0432-01", "type": "NDC" } ], "description": "TRAZODONE 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8085", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0443-01", "type": "NDC" } ], "description": "TRAZODONE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8113", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0064-35", "type": "NDC" } ], "description": "TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 8.9, "gross_charge": 13.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8118", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0055-35", "type": "NDC" } ], "description": "TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 16.93, "gross_charge": 26.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8120", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3301", "type": "HCPCS" }, { "code": "70121-1651-05", "type": "NDC" } ], "description": "TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 27.17, "gross_charge": 41.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8121", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00713-0655-40", "type": "NDC" } ], "description": "TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 GR", "billing_class": "facility", "discounted_cash": 167.18, "gross_charge": 257.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8132", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0750-25", "type": "NDC" } ], "description": "TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.39, "gross_charge": 6.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8134", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0328-00", "type": "NDC" } ], "description": "TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-81426", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0767-08", "type": "NDC" } ], "description": "DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.51, "gross_charge": 11.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-81428", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "66689-0203-08", "type": "NDC" } ], "description": "ACTIVATED CHARCOAL-SORBITOL 50 GRAM/240 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 240 ML", "billing_class": "facility", "discounted_cash": 87.98, "gross_charge": 135.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-81434", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3489", "type": "HCPCS" }, { "code": "25021-0830-82", "type": "NDC" } ], "description": "ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 132.7, "gross_charge": 204.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-81453", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3535", "type": "HCPCS" }, { "code": "00186-0372-28", "type": "NDC" } ], "description": "BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6.9 GR", "billing_class": "facility", "discounted_cash": 158.5, "gross_charge": 243.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-81454", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3535", "type": "HCPCS" }, { "code": "00186-0370-28", "type": "NDC" } ], "description": "BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 6 GR", "billing_class": "facility", "discounted_cash": 323.5, "gross_charge": 497.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8161", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-2401-01", "type": "NDC" } ], "description": "TRIFLUOPERAZINE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.16, "gross_charge": 6.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8164", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-8034-01", "type": "NDC" } ], "description": "TRIFLUOPERAZINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.32, "gross_charge": 6.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8166", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00591-5335-01", "type": "NDC" } ], "description": "TRIHEXYPHENIDYL 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-81696", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1299", "type": "HCPCS" }, { "code": "25682-0001-01", "type": "NDC" } ], "description": "ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 ML", "billing_class": "facility", "discounted_cash": 17641.1, "gross_charge": 27140.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8178", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3250", "type": "HCPCS" }, { "code": "42023-0119-25", "type": "NDC" } ], "description": "TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 189.51, "gross_charge": 291.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8182", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70954-0541-10", "type": "NDC" } ], "description": "TRIMETHOPRIM 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.37, "gross_charge": 9.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-81838", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2794", "type": "HCPCS" }, { "code": "50458-0309-11", "type": "NDC" } ], "description": "RISPERIDONE MICROSPHERES ER 12.5 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEAS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 974.61, "gross_charge": 1499.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82090", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16729-0096-12", "type": "NDC" } ], "description": "QUETIAPINE ER 300 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82091", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16729-0097-12", "type": "NDC" } ], "description": "QUETIAPINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.1, "gross_charge": 6.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82100", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "50474-0802-03", "type": "NDC" } ], "description": "ROTIGOTINE 2 MG/24 HOUR TRANSDERMAL 24 HOUR PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 57.1, "gross_charge": 87.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82134", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00487-9007-30", "type": "NDC" } ], "description": "SODIUM CHLORIDE 7 % FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 4.26, "gross_charge": 6.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82180", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9190", "type": "HCPCS" }, { "code": "63323-0117-51", "type": "NDC" } ], "description": "FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 75.53, "gross_charge": 116.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82200", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9190", "type": "HCPCS" }, { "code": "63323-0117-19", "type": "NDC" } ], "description": "FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 58.21, "gross_charge": 89.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82228", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9330", "type": "HCPCS" }, { "code": "72611-0785-02", "type": "NDC" } ], "description": "TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2.5 ML", "billing_class": "facility", "discounted_cash": 4202.61, "gross_charge": 6465.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82301", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0736", "type": "HCPCS" }, { "code": "25021-0115-06", "type": "NDC" } ], "description": "CLINDAMYCIN 150 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 26.52, "gross_charge": 40.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82307", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "47335-0236-83", "type": "NDC" } ], "description": "AMBRISENTAN 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21.32, "gross_charge": 32.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82308", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00378-4271-93", "type": "NDC" } ], "description": "AMBRISENTAN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21.32, "gross_charge": 32.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82464", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "80681-0041-00", "type": "NDC" } ], "description": "MELATONIN 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8250", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "70069-0121-01", "type": "NDC" } ], "description": "TROPICAMIDE 1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 22.88, "gross_charge": 35.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82504", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-7304-31", "type": "NDC" } ], "description": "RIVASTIGMINE 4.6 MG/24 HOUR TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.96, "gross_charge": 12.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-82505", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51991-0898-30", "type": "NDC" } ], "description": "RIVASTIGMINE 9.5 MG/24 HOUR TRANSDERMAL PATCH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.14, "gross_charge": 9.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8259", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "42023-0104-01", "type": "NDC" } ], "description": "TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 56.26, "gross_charge": 86.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8259", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "49281-0752-22", "type": "NDC" } ], "description": "TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.1 ML", "billing_class": "facility", "discounted_cash": 48.56, "gross_charge": 74.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8429", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-0310-11", "type": "NDC" } ], "description": "VALPROIC ACID 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8442", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "25021-0151-20", "type": "NDC" } ], "description": "VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 29.09, "gross_charge": 44.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8443", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00409-6534-01", "type": "NDC" } ], "description": "VANCOMYCIN 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 33.22, "gross_charge": 51.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8444", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "67457-0341-05", "type": "NDC" } ], "description": "VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 286.46, "gross_charge": 440.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-850", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00363-0075-64", "type": "NDC" } ], "description": "BACITRACIN 500 UNIT/GRAM TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 0.91, "gross_charge": 1.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8527", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00409-1144-02", "type": "NDC" } ], "description": "VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 25.64, "gross_charge": 39.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8527", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "42571-0313-75", "type": "NDC" } ], "description": "VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 37.9, "gross_charge": 58.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8528", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "23155-0486-01", "type": "NDC" } ], "description": "VERAPAMIL 120 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.87, "gross_charge": 5.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8529", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00591-0404-01", "type": "NDC" } ], "description": "VERAPAMIL 40 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.28, "gross_charge": 5.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8530", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "23155-0026-01", "type": "NDC" } ], "description": "VERAPAMIL 80 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-854", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0483-45", "type": "NDC" } ], "description": "NEOMYCIN-BACITRACN ZN-POLYMYX 3.5 MG-400 UNIT-5,000 UNIT/GRAM TOP OINT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 28.4 GR", "billing_class": "facility", "discounted_cash": 1.17, "gross_charge": 1.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-856", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24208-0555-55", "type": "NDC" } ], "description": "BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3.5 GR", "billing_class": "facility", "discounted_cash": 23.14, "gross_charge": 35.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8594", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9360", "type": "HCPCS" }, { "code": "63323-0278-10", "type": "NDC" } ], "description": "VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 186.71, "gross_charge": 287.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-860", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0815-65", "type": "NDC" } ], "description": "BACLOFEN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8639", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-2085-60", "type": "NDC" } ], "description": "VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8748", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-1219-01", "type": "NDC" } ], "description": "WARFARIN 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8749", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-1212-00", "type": "NDC" } ], "description": "WARFARIN 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8750", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-1213-00", "type": "NDC" } ], "description": "WARFARIN 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8751", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "65162-0766-10", "type": "NDC" } ], "description": "WARFARIN 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8752", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00832-1218-00", "type": "NDC" } ], "description": "WARFARIN 7.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.35, "gross_charge": 5.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-87869", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68682-0655-20", "type": "NDC" } ], "description": "DIAZEPAM 12.5 MG-15 MG-17.5 MG-20 MG RECTAL KIT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 359.48, "gross_charge": 553.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-87925", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9208", "type": "HCPCS" }, { "code": "00143-9531-01", "type": "NDC" } ], "description": "IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 136.24, "gross_charge": 209.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-87998", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49702-0223-18", "type": "NDC" } ], "description": "MARAVIROC 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 57.17, "gross_charge": 87.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88010", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q2009", "type": "HCPCS" }, { "code": "00069-5474-01", "type": "NDC" } ], "description": "FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 72.41, "gross_charge": 111.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88011", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "Q2009", "type": "HCPCS" }, { "code": "00069-5471-01", "type": "NDC" } ], "description": "FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 26.0, "gross_charge": 40.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88225", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49502-0605-61", "type": "NDC" } ], "description": "FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 12.74, "gross_charge": 19.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88241", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9211", "type": "HCPCS" }, { "code": "00013-2596-91", "type": "NDC" } ], "description": "IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 533.16, "gross_charge": 820.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88376", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9060", "type": "HCPCS" }, { "code": "68001-0609-33", "type": "NDC" } ], "description": "CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 98.57, "gross_charge": 151.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88583", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-5669-01", "type": "NDC" } ], "description": "CARBIDOPA 50 MG-LEVODOPA 200 MG-ENTACAPONE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.58, "gross_charge": 7.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88608", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00006-0227-61", "type": "NDC" } ], "description": "RALTEGRAVIR 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 71.56, "gross_charge": 110.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8865", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-4090-01", "type": "NDC" } ], "description": "ZINC CHLORIDE 1 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 65.72, "gross_charge": 101.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88704", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0675-11", "type": "NDC" } ], "description": "OSELTAMIVIR 30 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.94, "gross_charge": 7.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8874", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "75834-0170-02", "type": "NDC" } ], "description": "ZINC OXIDE 20 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 56.7 GR", "billing_class": "facility", "discounted_cash": 22.75, "gross_charge": 35.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8879", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00517-8005-25", "type": "NDC" } ], "description": "ZINC SULFATE 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 109.04, "gross_charge": 167.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8880", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00731-0401-06", "type": "NDC" } ], "description": "ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-88945", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "75834-0020-01", "type": "NDC" } ], "description": "CHOLECALCIFEROL (VITAMIN D3) 1,250 MCG (50,000 UNIT) CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.1, "gross_charge": 0.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-89201", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0328-31", "type": "NDC" } ], "description": "SEVELAMER CARBONATE 800 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.4, "gross_charge": 9.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-89284", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0641-11", "type": "NDC" } ], "description": "NEBIVOLOL 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.08, "gross_charge": 10.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-89286", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0652-21", "type": "NDC" } ], "description": "NEBIVOLOL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.6, "gross_charge": 11.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-89346", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0752-25", "type": "NDC" } ], "description": "CLOPIDOGREL 300 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 19.04, "gross_charge": 29.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-89350", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9305", "type": "HCPCS" }, { "code": "71288-0166-91", "type": "NDC" } ], "description": "PEMETREXED DISODIUM 100 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 82.78, "gross_charge": 127.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-89432", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59676-0570-01", "type": "NDC" } ], "description": "ETRAVIRINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27.66, "gross_charge": 42.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8962", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0578-21", "type": "NDC" } ], "description": "ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.37, "gross_charge": 15.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8963", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00264-2304-10", "type": "NDC" } ], "description": "ACETIC ACID 0.25 % IRRIGATION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 24.67, "gross_charge": 37.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8969", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "72578-0002-01", "type": "NDC" } ], "description": "ACYCLOVIR 200 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8970", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0681-47", "type": "NDC" } ], "description": "ACYCLOVIR 200 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 473 ML", "billing_class": "facility", "discounted_cash": 147.81, "gross_charge": 227.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8972", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0062-15", "type": "NDC" } ], "description": "ACYCLOVIR 800 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.93, "gross_charge": 6.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8975", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0153", "type": "HCPCS" }, { "code": "25021-0301-67", "type": "NDC" } ], "description": "ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 50.05, "gross_charge": 77.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8979", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43598-0452-02", "type": "NDC" } ], "description": "ALBENDAZOLE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 12.84, "gross_charge": 19.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-89791", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "62756-0071-64", "type": "NDC" } ], "description": "PANTOPRAZOLE DR 40 MG GRANULES DELAYED-RELEASE FOR SUSP IN PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.18, "gross_charge": 37.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8981", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "P9047", "type": "HCPCS" }, { "code": "00944-0493-04", "type": "NDC" } ], "description": "ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 155.45, "gross_charge": 239.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-8982", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "P9045", "type": "HCPCS" }, { "code": "00944-0495-05", "type": "NDC" } ], "description": "ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION (IO)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 160.1, "gross_charge": 246.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9002", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "50242-0085-27", "type": "NDC" } ], "description": "ALTEPLASE 100 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23242.18, "gross_charge": 35757.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9003", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2997", "type": "HCPCS" }, { "code": "50242-0044-13", "type": "NDC" } ], "description": "ALTEPLASE 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 11647.77, "gross_charge": 17919.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9014", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "46122-0432-40", "type": "NDC" } ], "description": "ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 5.82, "gross_charge": 8.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9020", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "57074-0001-77", "type": "NDC" } ], "description": "CALCIUM ACETATE 952 MG-ALUMINUM SULFATE 1,347 MG TOPICAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.26, "gross_charge": 6.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9049", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00000-0104-01", "type": "NDC" } ], "description": "PARENTERAL AMINO ACID 10 % COMBINATION NO.2 INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 121.97, "gross_charge": 187.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9062", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0035-23", "type": "NDC" } ], "description": "AMINOCAPROIC ACID 250 MG/ML (25 %) ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 4 ML", "billing_class": "facility", "discounted_cash": 15.02, "gross_charge": 23.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9063", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0739-95", "type": "NDC" } ], "description": "AMINOCAPROIC ACID 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 37.57, "gross_charge": 57.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9066", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0437-01", "type": "NDC" } ], "description": "AMIODARONE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.44, "gross_charge": 5.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9069", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0496-01", "type": "NDC" } ], "description": "AMLODIPINE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9070", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-6369-61", "type": "NDC" } ], "description": "AMLODIPINE 2.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9071", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0488-01", "type": "NDC" } ], "description": "AMLODIPINE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9083", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0295", "type": "HCPCS" }, { "code": "71288-0031-91", "type": "NDC" } ], "description": "AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 28.18, "gross_charge": 43.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9084", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0295", "type": "HCPCS" }, { "code": "00641-6117-10", "type": "NDC" } ], "description": "AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 30.81, "gross_charge": 47.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91046", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "90632", "type": "HCPCS" }, { "code": "00006-4096-01", "type": "NDC" } ], "description": "HEPATITIS A VIRUS VACCINE (PF) 50 UNIT/ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 237.58, "gross_charge": 365.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91185", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2850", "type": "HCPCS" }, { "code": "67066-0005-01", "type": "NDC" } ], "description": "SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2186.83, "gross_charge": 3364.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9119", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0665-05", "type": "NDC" } ], "description": "APRACLONIDINE 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 127.82, "gross_charge": 196.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91278", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2354", "type": "HCPCS" }, { "code": "00641-6174-10", "type": "NDC" } ], "description": "OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 24.86, "gross_charge": 38.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91279", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2354", "type": "HCPCS" }, { "code": "63323-0376-01", "type": "NDC" } ], "description": "OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.75 ML", "billing_class": "facility", "discounted_cash": 27.07, "gross_charge": 41.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91281", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2354", "type": "HCPCS" }, { "code": "63323-0377-01", "type": "NDC" } ], "description": "OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 39.1, "gross_charge": 60.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91300", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9033", "type": "HCPCS" }, { "code": "63459-0391-20", "type": "NDC" } ], "description": "BENDAMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7884.01, "gross_charge": 12129.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91408", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2785", "type": "HCPCS" }, { "code": "60505-6116-00", "type": "NDC" } ], "description": "REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 96.78, "gross_charge": 148.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91534", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69339-0162-98", "type": "NDC" } ], "description": "LUBIPROSTONE 8 MCG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27.66, "gross_charge": 42.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91651", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2212", "type": "HCPCS" }, { "code": "65649-0551-02", "type": "NDC" } ], "description": "METHYLNALTREXONE 12 MG/0.6 ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.4 ML", "billing_class": "facility", "discounted_cash": 362.86, "gross_charge": 558.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9183", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7500", "type": "HCPCS" }, { "code": "68084-0229-01", "type": "NDC" } ], "description": "AZATHIOPRINE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.0, "gross_charge": 6.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9185", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0457", "type": "HCPCS" }, { "code": "63323-0401-26", "type": "NDC" } ], "description": "AZTREONAM 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 87.94, "gross_charge": 135.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9186", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0457", "type": "HCPCS" }, { "code": "63323-0402-30", "type": "NDC" } ], "description": "AZTREONAM 2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 157.3, "gross_charge": 242.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91870", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-0668-82", "type": "NDC" } ], "description": "ALVIMOPAN 12 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 215.44, "gross_charge": 331.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-91965", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00338-0330-01", "type": "NDC" } ], "description": "THROMBIN (RECOMBINANT) 20,000 UNIT TOPICAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 681.2, "gross_charge": 1048.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9266", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0702", "type": "HCPCS" }, { "code": "00517-0720-01", "type": "NDC" } ], "description": "BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 44.43, "gross_charge": 68.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9268", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0245-01", "type": "NDC" } ], "description": "BETAXOLOL 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 108.0, "gross_charge": 166.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9285", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "37000-0477-09", "type": "NDC" } ], "description": "BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-92851", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59676-0562-01", "type": "NDC" } ], "description": "DARUNAVIR 600 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 74.04, "gross_charge": 113.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-92853", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7189", "type": "HCPCS" }, { "code": "00169-7201-01", "type": "NDC" } ], "description": "COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7494.47, "gross_charge": 11529.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-92854", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7189", "type": "HCPCS" }, { "code": "00169-7202-01", "type": "NDC" } ], "description": "COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14967.55, "gross_charge": 23027.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-92855", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7189", "type": "HCPCS" }, { "code": "00169-7205-01", "type": "NDC" } ], "description": "COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 37386.76, "gross_charge": 57518.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9289", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9040", "type": "HCPCS" }, { "code": "63323-0136-10", "type": "NDC" } ], "description": "BLEOMYCIN 15 UNIT/ML (IM/SC CONCENTRATION)", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 125.48, "gross_charge": 193.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-92895", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3373", "type": "HCPCS" }, { "code": "00338-3552-48", "type": "NDC" } ], "description": "VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 111.74, "gross_charge": 171.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-92897", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60505-3631-03", "type": "NDC" } ], "description": "DASATINIB 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 194.28, "gross_charge": 298.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-93084", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0282", "type": "HCPCS" }, { "code": "72078-0046-09", "type": "NDC" } ], "description": "AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 28.4, "gross_charge": 43.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9309", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0130-15", "type": "NDC" } ], "description": "BUMETANIDE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.68, "gross_charge": 7.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9310", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7016-61", "type": "NDC" } ], "description": "BUMETANIDE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.48, "gross_charge": 6.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9311", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0535-65", "type": "NDC" } ], "description": "BUMETANIDE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.26, "gross_charge": 8.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9321", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0351-01", "type": "NDC" } ], "description": "BUPROPION HCL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.07, "gross_charge": 7.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9322", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0340-01", "type": "NDC" } ], "description": "BUPROPION HCL 75 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.55, "gross_charge": 7.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9323", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0812-01", "type": "NDC" } ], "description": "BUSPIRONE 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9324", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0985-20", "type": "NDC" } ], "description": "BUSPIRONE 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.18, "gross_charge": 4.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9347", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0630", "type": "HCPCS" }, { "code": "72078-0038-02", "type": "NDC" } ], "description": "CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 464.04, "gross_charge": 713.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9350", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0345-01", "type": "NDC" } ], "description": "CALCITRIOL 0.25 MCG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.32, "gross_charge": 6.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-93566", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2802", "type": "HCPCS" }, { "code": "55513-0221-01", "type": "NDC" } ], "description": "ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8950.11, "gross_charge": 13769.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-93567", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2802", "type": "HCPCS" }, { "code": "55513-0222-01", "type": "NDC" } ], "description": "ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 17878.74, "gross_charge": 27505.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-93834", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68001-0113-06", "type": "NDC" } ], "description": "LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.58, "gross_charge": 5.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-93838", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0701", "type": "HCPCS" }, { "code": "00338-1301-48", "type": "NDC" } ], "description": "CEFEPIME 2 GRAM/100 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 154.21, "gross_charge": 237.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9385", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "24385-0485-47", "type": "NDC" } ], "description": "CALCIUM 200 MG (AS CALCIUM CARBONATE 500 MG) CHEWABLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.03, "gross_charge": 0.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-93931", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0405-79", "type": "NDC" } ], "description": "IPRATROPIUM 0.5 MG-ALBUTEROL 3 MG (2.5 MG BASE)/3 ML NEBULIZATION SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 3 ML", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-93936", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0759", "type": "HCPCS" }, { "code": "10122-0610-01", "type": "NDC" } ], "description": "CLEVIDIPINE 25 MG/50 ML INTRAVENOUS EMULSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 281.68, "gross_charge": 433.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9401", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0304-11", "type": "NDC" } ], "description": "CAPTOPRIL 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.36, "gross_charge": 8.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9403", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69292-0526-01", "type": "NDC" } ], "description": "CAPTOPRIL 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.5, "gross_charge": 10.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9406", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-9701-01", "type": "NDC" } ], "description": "CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9407", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0661-11", "type": "NDC" } ], "description": "CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.38, "gross_charge": 5.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9410", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9045", "type": "HCPCS" }, { "code": "63323-0167-21", "type": "NDC" } ], "description": "CARBOPLATIN 150 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 938.57, "gross_charge": 1443.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9413", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0675", "type": "HCPCS" }, { "code": "43598-0917-58", "type": "NDC" } ], "description": "CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 141.28, "gross_charge": 217.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-94158", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "77333-0844-10", "type": "NDC" } ], "description": "SODIUM CHLORIDE 1,000 MG SOLUBLE TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.16, "gross_charge": 0.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9417", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0238-05", "type": "NDC" } ], "description": "CARTEOLOL 1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 32.66, "gross_charge": 50.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-94219", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2404", "type": "HCPCS" }, { "code": "43066-0009-10", "type": "NDC" } ], "description": "NICARDIPINE 20 MG/200 ML(0.1 MG/ML) IN SOD CHLOR(ISO) INTRAVENOUS SOLN", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 200 ML", "billing_class": "facility", "discounted_cash": 138.42, "gross_charge": 212.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-94236", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00781-5625-01", "type": "NDC" } ], "description": "CARBIDOPA 18.75 MG-LEVODOPA 75 MG-ENTACAPONE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.58, "gross_charge": 7.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9436", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-3196-53", "type": "NDC" } ], "description": "CEFADROXIL 500 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9439", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "57237-0098-01", "type": "NDC" } ], "description": "CEFADROXIL 500 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 5.69, "gross_charge": 8.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-94563", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68682-0421-12", "type": "NDC" } ], "description": "TETRABENAZINE 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.96, "gross_charge": 38.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9458", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0525", "type": "HCPCS" }, { "code": "63323-0385-10", "type": "NDC" } ], "description": "CEFOTETAN 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 51.68, "gross_charge": 79.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9460", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0525", "type": "HCPCS" }, { "code": "63323-0386-20", "type": "NDC" } ], "description": "CEFOTETAN 2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 81.93, "gross_charge": 126.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9474", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0713", "type": "HCPCS" }, { "code": "25021-0127-20", "type": "NDC" } ], "description": "CEFTAZIDIME (IM) 1000 MG INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 35.04, "gross_charge": 53.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9487", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00409-7332-20", "type": "NDC" } ], "description": "CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 24.38, "gross_charge": 37.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9488", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00409-7335-21", "type": "NDC" } ], "description": "CEFTRIAXONE 2 GRAM SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27.1, "gross_charge": 41.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9489", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00409-7337-20", "type": "NDC" } ], "description": "CEFTRIAXONE 250 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.08, "gross_charge": 35.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9490", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00409-7338-20", "type": "NDC" } ], "description": "CEFTRIAXONE 500 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 23.46, "gross_charge": 36.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9492", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00264-3153-11", "type": "NDC" } ], "description": "CEFTRIAXONE 1 GRAM/50 ML IN DEXTROSE (ISO-OSMOT) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 67.34, "gross_charge": 103.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9493", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0696", "type": "HCPCS" }, { "code": "00264-3155-11", "type": "NDC" } ], "description": "CEFTRIAXONE 2 GRAM/50 ML IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 77.02, "gross_charge": 118.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9495", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0272-94", "type": "NDC" } ], "description": "CEFUROXIME AXETIL 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.58, "gross_charge": 13.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9496", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0283-94", "type": "NDC" } ], "description": "CEFUROXIME AXETIL 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.72, "gross_charge": 14.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9499", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0152-01", "type": "NDC" } ], "description": "CEPHALEXIN 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.51, "gross_charge": 5.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9500", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7337-61", "type": "NDC" } ], "description": "CEPHALEXIN 500 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.48, "gross_charge": 5.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9501", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-4175-73", "type": "NDC" } ], "description": "CEPHALEXIN 125 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.53, "gross_charge": 10.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9502", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00093-4177-74", "type": "NDC" } ], "description": "CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 6.7, "gross_charge": 10.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9516", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-0893-00", "type": "NDC" } ], "description": "CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 4.58, "gross_charge": 7.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9526", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1205", "type": "HCPCS" }, { "code": "25021-0305-66", "type": "NDC" } ], "description": "CHLOROTHIAZIDE SODIUM 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 116.71, "gross_charge": 179.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-95676", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16729-0132-12", "type": "NDC" } ], "description": "QUETIAPINE ER 50 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.25, "gross_charge": 5.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-95687", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0650-33", "type": "NDC" } ], "description": "MESALAMINE ER 0.375 GRAM CAPSULE,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.0, "gross_charge": 12.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-95691", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0713-08", "type": "NDC" } ], "description": "RUFINAMIDE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.04, "gross_charge": 7.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-95692", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0714-08", "type": "NDC" } ], "description": "RUFINAMIDE 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.37, "gross_charge": 9.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-95811", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "00409-5160-10", "type": "NDC" } ], "description": "ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.56, "gross_charge": 34.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-95849", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2562", "type": "HCPCS" }, { "code": "71288-0155-01", "type": "NDC" } ], "description": "PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1.2 ML", "billing_class": "facility", "discounted_cash": 473.56, "gross_charge": 728.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9598", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68462-0297-17", "type": "NDC" } ], "description": "CICLOPIROX 0.77 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 11.93, "gross_charge": 18.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9603", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0743", "type": "HCPCS" }, { "code": "63323-0322-93", "type": "NDC" } ], "description": "IMIPENEM-CILASTATIN 500 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 53.59, "gross_charge": 82.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9610", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "61314-0656-05", "type": "NDC" } ], "description": "CIPROFLOXACIN 0.3 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 17.06, "gross_charge": 26.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9615", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9065", "type": "HCPCS" }, { "code": "00143-9871-01", "type": "NDC" } ], "description": "CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 233.77, "gross_charge": 359.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9616", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0178-15", "type": "NDC" } ], "description": "CLARITHROMYCIN 250 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.76, "gross_charge": 10.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9617", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0651-25", "type": "NDC" } ], "description": "CLARITHROMYCIN 500 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.01, "gross_charge": 15.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9626", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0736", "type": "HCPCS" }, { "code": "43066-0993-24", "type": "NDC" } ], "description": "CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 51.54, "gross_charge": 79.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9627", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0736", "type": "HCPCS" }, { "code": "00781-3290-09", "type": "NDC" } ], "description": "CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 50 ML", "billing_class": "facility", "discounted_cash": 60.68, "gross_charge": 93.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9630", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42291-0076-30", "type": "NDC" } ], "description": "CLOBETASOL 0.05 % TOPICAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 14.59, "gross_charge": 22.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9631", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42291-0077-30", "type": "NDC" } ], "description": "CLOBETASOL 0.05 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 17.55, "gross_charge": 27.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9635", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0790-25", "type": "NDC" } ], "description": "CLOMIPRAMINE 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 20.15, "gross_charge": 31.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9637", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0861-01", "type": "NDC" } ], "description": "CLONAZEPAM 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.3, "gross_charge": 9.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9638", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51079-0882-20", "type": "NDC" } ], "description": "CLONAZEPAM 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9644", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00054-8146-22", "type": "NDC" } ], "description": "CLOTRIMAZOLE 10 MG TROCHE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 8.16, "gross_charge": 12.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9647", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0415-01", "type": "NDC" } ], "description": "CLOZAPINE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.39, "gross_charge": 6.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9648", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0404-01", "type": "NDC" } ], "description": "CLOZAPINE 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9681", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0770", "type": "HCPCS" }, { "code": "70594-0023-09", "type": "NDC" } ], "description": "COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 52.32, "gross_charge": 80.5, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9682", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50484-0010-30", "type": "NDC" } ], "description": "COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 250 UNIT/GRAM TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 748.96, "gross_charge": 1152.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9686", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0834", "type": "HCPCS" }, { "code": "00548-5900-00", "type": "NDC" } ], "description": "COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 81.67, "gross_charge": 125.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96930", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "71399-7401-05", "type": "NDC" } ], "description": "CHOLECALCIFEROL (VITAMIN D3) 10 MCG/ML (400 UNIT/ML) ORAL DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 3.12, "gross_charge": 4.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96948", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00078-0568-45", "type": "NDC" } ], "description": "ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 13.55, "gross_charge": 20.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96968", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7244-68", "type": "NDC" } ], "description": "LACOSAMIDE 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.44, "gross_charge": 11.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96969", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0687-57", "type": "NDC" } ], "description": "LACOSAMIDE 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.05, "gross_charge": 10.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96970", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "67877-0735-60", "type": "NDC" } ], "description": "LACOSAMIDE 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.54, "gross_charge": 5.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96971", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00904-7247-68", "type": "NDC" } ], "description": "LACOSAMIDE 200 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.04, "gross_charge": 9.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96972", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "C9254", "type": "HCPCS" }, { "code": "70710-1886-01", "type": "NDC" } ], "description": "LACOSAMIDE 200 MG/20 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 56.0, "gross_charge": 86.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96982", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9100", "type": "HCPCS" }, { "code": "61703-0305-38", "type": "NDC" } ], "description": "CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 66.1, "gross_charge": 101.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96984", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0635-30", "type": "NDC" } ], "description": "SILODOSIN 4 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96985", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0636-90", "type": "NDC" } ], "description": "SILODOSIN 8 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96986", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9155", "type": "HCPCS" }, { "code": "55566-8303-01", "type": "NDC" } ], "description": "DEGARELIX 80 MG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1277.38, "gross_charge": 1965.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96987", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9155", "type": "HCPCS" }, { "code": "55566-8403-01", "type": "NDC" } ], "description": "DEGARELIX 120 MG SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1963.06, "gross_charge": 3020.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-96989", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7178", "type": "HCPCS" }, { "code": "63833-0891-51", "type": "NDC" } ], "description": "FIBRINOGEN 1 GRAM (900 MG-1,300 MG) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3288.87, "gross_charge": 5059.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9699", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00065-0395-15", "type": "NDC" } ], "description": "CYCLOPENTOLATE 0.5 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 ML", "billing_class": "facility", "discounted_cash": 247.75, "gross_charge": 381.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9700", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00065-0397-02", "type": "NDC" } ], "description": "CYCLOPENTOLATE 2 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 116.51, "gross_charge": 179.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9701", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00065-0359-02", "type": "NDC" } ], "description": "CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 2 ML", "billing_class": "facility", "discounted_cash": 94.12, "gross_charge": 144.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9705", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7516", "type": "HCPCS" }, { "code": "00078-0109-01", "type": "NDC" } ], "description": "CYCLOSPORINE 250 MG/5 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 235.95, "gross_charge": 363.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9706", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7502", "type": "HCPCS" }, { "code": "00078-0241-61", "type": "NDC" } ], "description": "CYCLOSPORINE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 37.31, "gross_charge": 57.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9707", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J7515", "type": "HCPCS" }, { "code": "68084-0879-25", "type": "NDC" } ], "description": "CYCLOSPORINE 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.56, "gross_charge": 16.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97087", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00456-1512-60", "type": "NDC" } ], "description": "MILNACIPRAN 12.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 19.01, "gross_charge": 29.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97089", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00456-1550-60", "type": "NDC" } ], "description": "MILNACIPRAN 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 19.01, "gross_charge": 29.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9716", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "78670-0003-67", "type": "NDC" } ], "description": "DANTROLENE 20 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 250.7, "gross_charge": 385.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9717", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00115-4433-01", "type": "NDC" } ], "description": "DANTROLENE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 6.04, "gross_charge": 9.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9718", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0300-21", "type": "NDC" } ], "description": "DANTROLENE 25 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.59, "gross_charge": 8.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9723", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0895", "type": "HCPCS" }, { "code": "63323-0597-10", "type": "NDC" } ], "description": "DEFEROXAMINE 500 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 65.88, "gross_charge": 101.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97252", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1163", "type": "HCPCS" }, { "code": "00641-9217-01", "type": "NDC" } ], "description": "DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 22.68, "gross_charge": 34.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97255", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J2354", "type": "HCPCS" }, { "code": "63323-0378-05", "type": "NDC" } ], "description": "OCTREOTIDE ACETATE 200 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.125 ML", "billing_class": "facility", "discounted_cash": 23.3, "gross_charge": 35.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9726", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0691-11", "type": "NDC" } ], "description": "DEMECLOCYCLINE 150 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 14.92, "gross_charge": 22.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97343", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "J3030", "type": "HCPCS" }, { "code": "55150-0173-05", "type": "NDC" } ], "description": "SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 33.31, "gross_charge": 51.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97353", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00178-0800-01", "type": "NDC" } ], "description": "CALCIUM 200 MG (AS CITRATE)-VITAMIN D3 6.25 MCG (250 UNIT) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.06, "gross_charge": 0.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97382", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "68001-0114-06", "type": "NDC" } ], "description": "LEVETIRACETAM ER 750 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.77, "gross_charge": 5.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97463", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "50268-0866-15", "type": "NDC" } ], "description": "CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 0.13, "gross_charge": 0.2, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9748", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2597", "type": "HCPCS" }, { "code": "69918-0901-11", "type": "NDC" } ], "description": "DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 32.89, "gross_charge": 50.6, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9751", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "21922-0004-04", "type": "NDC" } ], "description": "DESONIDE 0.05 % TOPICAL OINTMENT", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 15 GR", "billing_class": "facility", "discounted_cash": 30.65, "gross_charge": 47.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9759", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J7100", "type": "HCPCS" }, { "code": "00409-7418-13", "type": "NDC" } ], "description": "DEXTRAN 40 10 % IN 5 % DEXTROSE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 500 ML", "billing_class": "facility", "discounted_cash": 196.17, "gross_charge": 301.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9774", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00121-0638-00", "type": "NDC" } ], "description": "DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML ORAL SYRUP", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 5 ML", "billing_class": "facility", "discounted_cash": 1.14, "gross_charge": 1.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9788", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7121", "type": "HCPCS" }, { "code": "00338-0125-04", "type": "NDC" } ], "description": "DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97893", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "31722-0868-31", "type": "NDC" } ], "description": "TOLVAPTAN 15 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 115.67, "gross_charge": 177.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97894", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "67877-0636-33", "type": "NDC" } ], "description": "TOLVAPTAN 30 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 101.3, "gross_charge": 155.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9791", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0683-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97915", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "42195-0550-14", "type": "NDC" } ], "description": "CIPROFLOXACIN 0.2 % EAR DROPS IN A DROPPERETTE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 21.16, "gross_charge": 32.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9795", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0803-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.38, "gross_charge": 71.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-97979", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "49884-0212-55", "type": "NDC" } ], "description": "RISPERIDONE 0.25 MG DISINTEGRATING TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.0, "gross_charge": 13.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9799", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0669-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9800", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0663-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9801", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0671-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 46.38, "gross_charge": 71.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-98034", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00032-0046-70", "type": "NDC" } ], "description": "LIPASE-PROTEASE-AMYLASE (PORK)6,000-19,000-30,000 UNIT CAPSULE,DEL REL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 7.05, "gross_charge": 10.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9804", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0673-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9807", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3480", "type": "HCPCS" }, { "code": "00338-0675-04", "type": "NDC" } ], "description": "POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 49.11, "gross_charge": 75.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9812", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00338-0077-04", "type": "NDC" } ], "description": "DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9814", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "00338-0085-04", "type": "NDC" } ], "description": "DEXTROSE 5 % AND 0.45 % NACL IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9814", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J3490", "type": "HCPCS" }, { "code": "63323-0869-75", "type": "NDC" } ], "description": "DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 250 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9815", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "J7042", "type": "HCPCS" }, { "code": "00338-0089-04", "type": "NDC" } ], "description": "DEXTROSE 5 % AND 0.9 % NACL IV BOLUS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1000 ML", "billing_class": "facility", "discounted_cash": 43.65, "gross_charge": 67.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-98249", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9190", "type": "HCPCS" }, { "code": "63323-0117-69", "type": "NDC" } ], "description": "FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 100 ML", "billing_class": "facility", "discounted_cash": 97.47, "gross_charge": 149.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-98253", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "24510-0050-10", "type": "NDC" } ], "description": "TAPENTADOL 50 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 25.87, "gross_charge": 39.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-98329", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00024-4142-60", "type": "NDC" } ], "description": "DRONEDARONE 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 27.85, "gross_charge": 42.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-98372", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "16729-0272-10", "type": "NDC" } ], "description": "PRASUGREL HCL 5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.55, "gross_charge": 7.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-98373", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0883-11", "type": "NDC" } ], "description": "PRASUGREL HCL 10 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.3, "gross_charge": 8.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9859", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1110", "type": "HCPCS" }, { "code": "81284-0411-00", "type": "NDC" } ], "description": "DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.5 ML", "billing_class": "facility", "discounted_cash": 96.75, "gross_charge": 148.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-988", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0214-01", "type": "NDC" } ], "description": "BENZONATATE 100 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-989", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "71399-9474-05", "type": "NDC" } ], "description": "BENZOYL PEROXIDE 10 % TOPICAL GEL", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 42.5 GR", "billing_class": "facility", "discounted_cash": 16.02, "gross_charge": 24.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9891", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1245", "type": "HCPCS" }, { "code": "00641-2569-41", "type": "NDC" } ], "description": "DIPYRIDAMOLE 5 MG/ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 78.1, "gross_charge": 120.15, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9892", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1250", "type": "HCPCS" }, { "code": "00409-2344-02", "type": "NDC" } ], "description": "DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 41.76, "gross_charge": 64.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9894", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0836-25", "type": "NDC" } ], "description": "DOXAZOSIN 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.42, "gross_charge": 6.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9895", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0851-01", "type": "NDC" } ], "description": "DOXAZOSIN 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.9, "gross_charge": 6.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9896", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0862-01", "type": "NDC" } ], "description": "DOXAZOSIN 4 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.96, "gross_charge": 6.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9902", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0657-01", "type": "NDC" } ], "description": "DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 12.16, "gross_charge": 18.7, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9904", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "67877-0753-60", "type": "NDC" } ], "description": "DRONABINOL 2.5 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 10.01, "gross_charge": 15.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9938", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0885", "type": "HCPCS" }, { "code": "59676-0310-01", "type": "NDC" } ], "description": "EPOETIN ALFA 10,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 478.82, "gross_charge": 736.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9939", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0885", "type": "HCPCS" }, { "code": "59676-0302-01", "type": "NDC" } ], "description": "EPOETIN ALFA 2,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 189.15, "gross_charge": 291.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9940", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0885", "type": "HCPCS" }, { "code": "59676-0303-00", "type": "NDC" } ], "description": "EPOETIN ALFA 3,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 273.0, "gross_charge": 420.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9941", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J0885", "type": "HCPCS" }, { "code": "59676-0304-01", "type": "NDC" } ], "description": "EPOETIN ALFA 4,000 UNIT/ML INJECTION SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 356.85, "gross_charge": 549.0, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9943", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "69367-0283-02", "type": "NDC" } ], "description": "ERGOCALCIFEROL (VITAMIN D2) 200 MCG/ML (8,000 UNIT/ML) ORAL DROPS", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 0.25 ML", "billing_class": "facility", "discounted_cash": 5.92, "gross_charge": 9.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99443", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "60687-0765-13", "type": "NDC" } ], "description": "VALGANCICLOVIR 50 MG/ML ORAL SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 88 ML", "billing_class": "facility", "discounted_cash": 392.21, "gross_charge": 603.4, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99445", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0852-11", "type": "NDC" } ], "description": "LEVONORGESTREL 1.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 2.18, "gross_charge": 3.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99454", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43068-0102-02", "type": "NDC" } ], "description": "ILOPERIDONE 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 60.68, "gross_charge": 93.35, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99456", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "43068-0106-02", "type": "NDC" } ], "description": "ILOPERIDONE 6 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 73.97, "gross_charge": 113.8, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9957", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1805", "type": "HCPCS" }, { "code": "67457-0182-10", "type": "NDC" } ], "description": "ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 41.44, "gross_charge": 63.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99610", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9263", "type": "HCPCS" }, { "code": "61703-0363-18", "type": "NDC" } ], "description": "OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 10 ML", "billing_class": "facility", "discounted_cash": 171.24, "gross_charge": 263.45, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99612", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J9263", "type": "HCPCS" }, { "code": "61703-0363-22", "type": "NDC" } ], "description": "OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 20 ML", "billing_class": "facility", "discounted_cash": 280.77, "gross_charge": 431.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9967", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51862-0333-01", "type": "NDC" } ], "description": "ESTRADIOL 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.22, "gross_charge": 4.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9968", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "51862-0334-01", "type": "NDC" } ], "description": "ESTRADIOL 2 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.15, "gross_charge": 4.85, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9969", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "45802-0097-35", "type": "NDC" } ], "description": "ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 42.5 GR", "billing_class": "facility", "discounted_cash": 186.06, "gross_charge": 286.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99694", "type": "CDM" }, { "code": "250", "type": "RC" }, { "code": "25000049", "type": "HCPCS" }, { "code": "43598-0478-90", "type": "NDC" } ], "description": "SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 20.77, "gross_charge": 31.95, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99702", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J2426", "type": "HCPCS" }, { "code": "50458-0563-01", "type": "NDC" } ], "description": "PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 7412.44, "gross_charge": 11403.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9972", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1410", "type": "HCPCS" }, { "code": "00046-0749-05", "type": "NDC" } ], "description": "CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1157.42, "gross_charge": 1780.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9973", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00046-1100-81", "type": "NDC" } ], "description": "CONJUGATED ESTROGENS 0.3 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.28, "gross_charge": 25.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9974", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00046-1102-81", "type": "NDC" } ], "description": "CONJUGATED ESTROGENS 0.625 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 16.28, "gross_charge": 25.05, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99754", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "59762-2012-01", "type": "NDC" } ], "description": "ASENAPINE 5 MG SUBLINGUAL TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 9.91, "gross_charge": 15.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9977", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00046-0872-21", "type": "NDC" } ], "description": "CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 30 GR", "billing_class": "facility", "discounted_cash": 1160.41, "gross_charge": 1785.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9979", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1807", "type": "HCPCS" }, { "code": "42023-0157-01", "type": "NDC" } ], "description": "ETHACRYNATE SODIUM 50 MG INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 1700.34, "gross_charge": 2615.9, "setting": "both" } ] }, { "code_information": [ { "code": "RX-998", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0381-11", "type": "NDC" } ], "description": "BENZTROPINE 0.5 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.67, "gross_charge": 5.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9980", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "25010-0215-15", "type": "NDC" } ], "description": "ETHACRYNIC ACID 25 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 48.91, "gross_charge": 75.25, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9982", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68180-0280-01", "type": "NDC" } ], "description": "ETHAMBUTOL 100 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.61, "gross_charge": 5.55, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9983", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0280-01", "type": "NDC" } ], "description": "ETHAMBUTOL 400 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.32, "gross_charge": 6.65, "setting": "both" } ] }, { "code_information": [ { "code": "RX-99835", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "00228-2850-11", "type": "NDC" } ], "description": "GUANFACINE ER 1 MG TABLET,EXTENDED RELEASE 24 HR", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 4.39, "gross_charge": 6.75, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9984", "type": "CDM" }, { "code": "636", "type": "RC" }, { "code": "J1430", "type": "HCPCS" }, { "code": "67871-4790-06", "type": "NDC" } ], "description": "ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 ML", "billing_class": "facility", "discounted_cash": 780.84, "gross_charge": 1201.3, "setting": "both" } ] }, { "code_information": [ { "code": "RX-9989", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "23155-0532-01", "type": "NDC" } ], "description": "ETHOSUXIMIDE 250 MG CAPSULE", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 5.26, "gross_charge": 8.1, "setting": "both" } ] }, { "code_information": [ { "code": "RX-999", "type": "CDM" }, { "code": "637", "type": "RC" }, { "code": "63700001", "type": "HCPCS" }, { "code": "68084-0388-11", "type": "NDC" } ], "description": "BENZTROPINE 1 MG TABLET", "drug_information": { "type": "EA", "unit": 1.0 }, "standard_charges": [ { "additional_generic_notes": "Gross Charge Type: Pharmacy | NDC EA = 1 UN", "billing_class": "facility", "discounted_cash": 3.64, "gross_charge": 5.6, "setting": "both" } ] }, { "code_information": [ { "code": "67915", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67916", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67917", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67921", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67922", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67923", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67924", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67930", "type": "HCPCS" } ], "description": "Repair eyelid wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67935", "type": "HCPCS" } ], "description": "Repair eyelid wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67938", "type": "HCPCS" } ], "description": "Remove eyelid foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67950", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67961", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67966", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67971", "type": "HCPCS" } ], "description": "Reconstruction of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67973", "type": "HCPCS" } ], "description": "Reconstruction of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67974", "type": "HCPCS" } ], "description": "Reconstruction of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67975", "type": "HCPCS" } ], "description": "Reconstruction of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67999", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68020", "type": "HCPCS" } ], "description": "Incise/drain eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68040", "type": "HCPCS" } ], "description": "Treatment of eyelid lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68100", "type": "HCPCS" } ], "description": "Biopsy of eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68110", "type": "HCPCS" } ], "description": "Remove eyelid lining lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68115", "type": "HCPCS" } ], "description": "Remove eyelid lining lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68130", "type": "HCPCS" } ], "description": "Remove eyelid lining lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68135", "type": "HCPCS" } ], "description": "Remove eyelid lining lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68200", "type": "HCPCS" } ], "description": "Treat eyelid by injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68320", "type": "HCPCS" } ], "description": "Revise/graft eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68325", "type": "HCPCS" } ], "description": "Revise/graft eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68326", "type": "HCPCS" } ], "description": "Revise/graft eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68328", "type": "HCPCS" } ], "description": "Revise/graft eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68330", "type": "HCPCS" } ], "description": "Revise eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68335", "type": "HCPCS" } ], "description": "Revise/graft eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68340", "type": "HCPCS" } ], "description": "Separate eyelid adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68360", "type": "HCPCS" } ], "description": "Revise eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68362", "type": "HCPCS" } ], "description": "Revise eyelid lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68371", "type": "HCPCS" } ], "description": "Harvest eye tissue alograft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68399", "type": "HCPCS" } ], "description": "Eyelid lining surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68400", "type": "HCPCS" } ], "description": "Incise/drain tear gland", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68420", "type": "HCPCS" } ], "description": "Incise/drain tear sac", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68440", "type": "HCPCS" } ], "description": "Incise tear duct opening", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68500", "type": "HCPCS" } ], "description": "Removal of tear gland", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68505", "type": "HCPCS" } ], "description": "Partial removal tear gland", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68510", "type": "HCPCS" } ], "description": "Biopsy of tear gland", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68520", "type": "HCPCS" } ], "description": "Removal of tear sac", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68525", "type": "HCPCS" } ], "description": "Biopsy of tear sac", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68530", "type": "HCPCS" } ], "description": "Clearance of tear duct", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68540", "type": "HCPCS" } ], "description": "Remove tear gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68550", "type": "HCPCS" } ], "description": "Remove tear gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68700", "type": "HCPCS" } ], "description": "Repair tear ducts", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68705", "type": "HCPCS" } ], "description": "Revise tear duct opening", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68720", "type": "HCPCS" } ], "description": "Create tear sac drain", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68745", "type": "HCPCS" } ], "description": "Create tear duct drain", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68750", "type": "HCPCS" } ], "description": "Create tear duct drain", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68760", "type": "HCPCS" } ], "description": "Close tear duct opening", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68761", "type": "HCPCS" } ], "description": "Close tear duct opening", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68770", "type": "HCPCS" } ], "description": "Close tear system fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68801", "type": "HCPCS" } ], "description": "Dilate tear duct opening", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68810", "type": "HCPCS" } ], "description": "Probe nasolacrimal duct", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68811", "type": "HCPCS" } ], "description": "Probe nasolacrimal duct", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68815", "type": "HCPCS" } ], "description": "Probe nasolacrimal duct", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68816", "type": "HCPCS" } ], "description": "Probe nl duct w/balloon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68840", "type": "HCPCS" } ], "description": "Explore/irrigate tear ducts", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68841", "type": "HCPCS" } ], "description": "Insj rx elut implt lac canal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "68899", "type": "HCPCS" } ], "description": "Tear duct system surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69000", "type": "HCPCS" } ], "description": "Drain external ear lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69005", "type": "HCPCS" } ], "description": "Drain external ear lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69020", "type": "HCPCS" } ], "description": "Drain outer ear canal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69100", "type": "HCPCS" } ], "description": "Biopsy of external ear", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69105", "type": "HCPCS" } ], "description": "Biopsy of external ear canal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69110", "type": "HCPCS" } ], "description": "Remove external ear partial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69120", "type": "HCPCS" } ], "description": "Removal of external ear", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69140", "type": "HCPCS" } ], "description": "Remove ear canal lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69145", "type": "HCPCS" } ], "description": "Remove ear canal lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69150", "type": "HCPCS" } ], "description": "Extensive ear canal surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69155", "type": "HCPCS" } ], "description": "Extensive ear/neck surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69200", "type": "HCPCS" } ], "description": "Clear outer ear canal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69205", "type": "HCPCS" } ], "description": "Clear outer ear canal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69209", "type": "HCPCS" } ], "description": "Remove impacted ear wax uni", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69210", "type": "HCPCS" } ], "description": "Remove impacted ear wax uni", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69220", "type": "HCPCS" } ], "description": "Clean out mastoid cavity", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69222", "type": "HCPCS" } ], "description": "Clean out mastoid cavity", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69300", "type": "HCPCS" } ], "description": "Revise external ear", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69310", "type": "HCPCS" } ], "description": "Rebuild outer ear canal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69320", "type": "HCPCS" } ], "description": "Rebuild outer ear canal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69399", "type": "HCPCS" } ], "description": "Outer ear surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69420", "type": "HCPCS" } ], "description": "Incision of eardrum", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69421", "type": "HCPCS" } ], "description": "Incision of eardrum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69424", "type": "HCPCS" } ], "description": "Remove ventilating tube", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69433", "type": "HCPCS" } ], "description": "Create eardrum opening", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69436", "type": "HCPCS" } ], "description": "Create eardrum opening", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69440", "type": "HCPCS" } ], "description": "Exploration of middle ear", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69450", "type": "HCPCS" } ], "description": "Eardrum revision", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69501", "type": "HCPCS" } ], "description": "Mastoidectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69502", "type": "HCPCS" } ], "description": "Mastoidectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69505", "type": "HCPCS" } ], "description": "Remove mastoid structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69511", "type": "HCPCS" } ], "description": "Extensive mastoid surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69530", "type": "HCPCS" } ], "description": "Extensive mastoid surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69535", "type": "HCPCS" } ], "description": "Remove part of temporal bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69540", "type": "HCPCS" } ], "description": "Remove ear lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69550", "type": "HCPCS" } ], "description": "Remove ear lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69552", "type": "HCPCS" } ], "description": "Remove ear lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69554", "type": "HCPCS" } ], "description": "Remove ear lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69601", "type": "HCPCS" } ], "description": "Mastoid surgery revision", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69602", "type": "HCPCS" } ], "description": "Mastoid surgery revision", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69603", "type": "HCPCS" } ], "description": "Mastoid surgery revision", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69604", "type": "HCPCS" } ], "description": "Mastoid surgery revision", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69610", "type": "HCPCS" } ], "description": "Repair of eardrum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69620", "type": "HCPCS" } ], "description": "Repair of eardrum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69631", "type": "HCPCS" } ], "description": "Repair eardrum structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69632", "type": "HCPCS" } ], "description": "Rebuild eardrum structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69633", "type": "HCPCS" } ], "description": "Rebuild eardrum structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69635", "type": "HCPCS" } ], "description": "Repair eardrum structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69636", "type": "HCPCS" } ], "description": "Rebuild eardrum structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69637", "type": "HCPCS" } ], "description": "Rebuild eardrum structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69641", "type": "HCPCS" } ], "description": "Revise middle ear & mastoid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69642", "type": "HCPCS" } ], "description": "Revise middle ear & mastoid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69643", "type": "HCPCS" } ], "description": "Revise middle ear & mastoid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69644", "type": "HCPCS" } ], "description": "Revise middle ear & mastoid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69645", "type": "HCPCS" } ], "description": "Revise middle ear & mastoid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69646", "type": "HCPCS" } ], "description": "Revise middle ear & mastoid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69650", "type": "HCPCS" } ], "description": "Release middle ear bone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69660", "type": "HCPCS" } ], "description": "Revise middle ear bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69661", "type": "HCPCS" } ], "description": "Revise middle ear bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69662", "type": "HCPCS" } ], "description": "Revise middle ear bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69666", "type": "HCPCS" } ], "description": "Repair middle ear structures", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69667", "type": "HCPCS" } ], "description": "Repair middle ear structures", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69670", "type": "HCPCS" } ], "description": "Remove mastoid air cells", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69676", "type": "HCPCS" } ], "description": "Remove middle ear nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69700", "type": "HCPCS" } ], "description": "Close mastoid fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69705", "type": "HCPCS" } ], "description": "Nps surg dilat eust tube uni", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69706", "type": "HCPCS" } ], "description": "Nps surg dilat eust tube bi", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69710", "type": "HCPCS" } ], "description": "Implant/replace hearing aid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69711", "type": "HCPCS" } ], "description": "Remove/repair hearing aid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69714", "type": "HCPCS" } ], "description": "Implant Temple Bone W/Stimul", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69716", "type": "HCPCS" } ], "description": "Impltj oi implt skl tc esp", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69717", "type": "HCPCS" } ], "description": "Temple Bone Implant Revision", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69719", "type": "HCPCS" } ], "description": "Revj/rplcmt oi implt tc esp", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69720", "type": "HCPCS" } ], "description": "Release facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69725", "type": "HCPCS" } ], "description": "Release facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69726", "type": "HCPCS" } ], "description": "Rmvl oi implt skl perq esp", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69727", "type": "HCPCS" } ], "description": "Rmvl oi implt skl tc esp", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69728", "type": "HCPCS" } ], "description": "Rmv ntr oi imp sktc esp>=100", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69729", "type": "HCPCS" } ], "description": "Impl oi implt sk tc esp>=100", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69730", "type": "HCPCS" } ], "description": "Rplc oi implt sk tc esp>=100", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69740", "type": "HCPCS" } ], "description": "Repair facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69745", "type": "HCPCS" } ], "description": "Repair facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69799", "type": "HCPCS" } ], "description": "Middle ear surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69801", "type": "HCPCS" } ], "description": "Incise inner ear", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69805", "type": "HCPCS" } ], "description": "Explore inner ear", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69806", "type": "HCPCS" } ], "description": "Explore inner ear", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69905", "type": "HCPCS" } ], "description": "Remove inner ear", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69910", "type": "HCPCS" } ], "description": "Remove inner ear & mastoid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69915", "type": "HCPCS" } ], "description": "Incise inner ear nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69930", "type": "HCPCS" } ], "description": "Implant cochlear device", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 31792.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31792.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69949", "type": "HCPCS" } ], "description": "Inner ear surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69950", "type": "HCPCS" } ], "description": "Incise inner ear nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69955", "type": "HCPCS" } ], "description": "Release facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69960", "type": "HCPCS" } ], "description": "Release inner ear canal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69970", "type": "HCPCS" } ], "description": "Remove inner ear lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "69979", "type": "HCPCS" } ], "description": "Temporal bone surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92920", "type": "HCPCS" } ], "description": "Prq cardiac angioplast 1 art", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92924", "type": "HCPCS" } ], "description": "Prq card angio/athrect 1 art", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92928", "type": "HCPCS" } ], "description": "Prq card stent w/angio 1 vsl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92933", "type": "HCPCS" } ], "description": "Prq card stent/ath/angio", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92937", "type": "HCPCS" } ], "description": "Prq revasc byp graft 1 vsl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92941", "type": "HCPCS" } ], "description": "Prq card revasc mi 1 vsl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92943", "type": "HCPCS" } ], "description": "Prq card revasc chronic 1vsl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92975", "type": "HCPCS" } ], "description": "Dissolve clot heart vessel", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92977", "type": "HCPCS" } ], "description": "Dissolve clot heart vessel", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92986", "type": "HCPCS" } ], "description": "Revision of aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92987", "type": "HCPCS" } ], "description": "Revision of mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92990", "type": "HCPCS" } ], "description": "Revision of pulmonary valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93451", "type": "HCPCS" } ], "description": "Right heart cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93452", "type": "HCPCS" } ], "description": "Left hrt cath w/ventrclgrphy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93453", "type": "HCPCS" } ], "description": "R&l hrt cath w/ventriclgrphy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93454", "type": "HCPCS" } ], "description": "Coronary artery angio s&i", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93455", "type": "HCPCS" } ], "description": "Coronary art/grft angio s&i", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93456", "type": "HCPCS" } ], "description": "R hrt coronary artery angio", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93457", "type": "HCPCS" } ], "description": "R hrt art/grft angio", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93458", "type": "HCPCS" } ], "description": "L hrt artery/ventricle angio", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93459", "type": "HCPCS" } ], "description": "L hrt art/grft angio", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93460", "type": "HCPCS" } ], "description": "R&l hrt art/ventricle angio", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93461", "type": "HCPCS" } ], "description": "R&l hrt art/ventricle angio", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93503", "type": "HCPCS" } ], "description": "Insert/place heart catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93505", "type": "HCPCS" } ], "description": "Biopsy of heart lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93580", "type": "HCPCS" } ], "description": "Transcath closure of asd", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93581", "type": "HCPCS" } ], "description": "Transcath closure of vsd", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93582", "type": "HCPCS" } ], "description": "Perq transcath closure pda", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93583", "type": "HCPCS" } ], "description": "Perq transcath septal reduxn", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93590", "type": "HCPCS" } ], "description": "Perq transcath cls mitral", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93591", "type": "HCPCS" } ], "description": "Perq transcath cls aortic", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93593", "type": "HCPCS" } ], "description": "R hrt cath chd nml nt cnj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93594", "type": "HCPCS" } ], "description": "R hrt cath chd abnl nt cnj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93595", "type": "HCPCS" } ], "description": "L hrt cath chd nm/abn nt cnj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93596", "type": "HCPCS" } ], "description": "R&l hrt cath chd nml nt cnj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93597", "type": "HCPCS" } ], "description": "R&l hrt cath chd abnl nt cnj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93650", "type": "HCPCS" } ], "description": "Ablate heart dysrhythm focus", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 7520.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93653", "type": "HCPCS" } ], "description": "Ep & ablate supravent arrhyt", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 25202.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25202.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93654", "type": "HCPCS" } ], "description": "Ep & ablate ventric tachy", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 25202.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25202.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93656", "type": "HCPCS" } ], "description": "Tx atrial fib pulm vein isol", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 25202.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25202.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96574", "type": "HCPCS" } ], "description": "Dbrdmt prmlg les w/pdt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96920", "type": "HCPCS" } ], "description": "Laser tx skin < 250 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96921", "type": "HCPCS" } ], "description": "Laser tx skin 250-500 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96922", "type": "HCPCS" } ], "description": "Laser tx skin >500 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97597", "type": "HCPCS" } ], "description": "Rmvl devital tis 20 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97602", "type": "HCPCS" } ], "description": "Wound(s) care non-selective", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C1062", "type": "HCPCS" } ], "description": "Intravertebral fx aug impl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C2596", "type": "HCPCS" } ], "description": "Probe, robotic, water-jet", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C5271", "type": "HCPCS" } ], "description": "Low cost skin substitute app", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C5273", "type": "HCPCS" } ], "description": "Low cost skin substitute app", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C5275", "type": "HCPCS" } ], "description": "Low cost skin substitute app", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C5277", "type": "HCPCS" } ], "description": "Low cost skin substitute app", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7500", "type": "HCPCS" } ], "description": "Deb bone 20 cm2 w/drug dev", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7501", "type": "HCPCS" } ], "description": "Perc bx breast lesions stero", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7502", "type": "HCPCS" } ], "description": "Perc bx breast lesions mr", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7503", "type": "HCPCS" } ], "description": "Open exc cerv node(s) w/ id", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7504", "type": "HCPCS" } ], "description": "Perq cvt&ls inj vert bodies", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7505", "type": "HCPCS" } ], "description": "Perq ls&cvt inj vert bodies", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7506", "type": "HCPCS" } ], "description": "Fusion of finger joints", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7507", "type": "HCPCS" } ], "description": "Perq thor&lumb vert aug", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7508", "type": "HCPCS" } ], "description": "Perq lumb&thor vert aug", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7509", "type": "HCPCS" } ], "description": "Dx bronch w/ navigation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7510", "type": "HCPCS" } ], "description": "Bronch/lavag w/ navigation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7511", "type": "HCPCS" } ], "description": "Bronch/bpsy(s) w/ navigation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7512", "type": "HCPCS" } ], "description": "Bronch/bpsy(s) w/ ebus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7513", "type": "HCPCS" } ], "description": "Cath/angio dialcir w/aplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7514", "type": "HCPCS" } ], "description": "Cath/angio dial cir w/stents", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7515", "type": "HCPCS" } ], "description": "Cath/angio dial cir w/embol", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7516", "type": "HCPCS" } ], "description": "Cor angio w/ ivus or oct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7517", "type": "HCPCS" } ], "description": "Cor angio w/ilic/fem angio", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7518", "type": "HCPCS" } ], "description": "Cor/gft angio w/ ivus or oct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7519", "type": "HCPCS" } ], "description": "Cor/gft angio w/ flow resrv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7520", "type": "HCPCS" } ], "description": "Cor/gft angio w/ilic/fem ang", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7521", "type": "HCPCS" } ], "description": "R hrt angio w/ ivus or oct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7522", "type": "HCPCS" } ], "description": "R hrt angio w/flow resrv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7523", "type": "HCPCS" } ], "description": "L hrt angio w/ ivus or oct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7524", "type": "HCPCS" } ], "description": "L hrt angio w/flow resrv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7525", "type": "HCPCS" } ], "description": "L hrt gft ang w/ ivus or oct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7526", "type": "HCPCS" } ], "description": "L hrt gft ang w/flow resrv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7527", "type": "HCPCS" } ], "description": "R&l hrt angio w/ ivus or oct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7528", "type": "HCPCS" } ], "description": "R&l hrt angio w/flow resrv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7529", "type": "HCPCS" } ], "description": "R&l hrt gft ang w/flow resrv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7530", "type": "HCPCS" } ], "description": "Cath/aplasty dial cir w/stnt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7531", "type": "HCPCS" } ], "description": "Angio fem/pop w/ us", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7532", "type": "HCPCS" } ], "description": "Angio w/ us non-coronary", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7533", "type": "HCPCS" } ], "description": "Ptca w/ plcmt brachytx dev", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7534", "type": "HCPCS" } ], "description": "Fem/pop revasc w/arthr & us", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7535", "type": "HCPCS" } ], "description": "Fem/pop revasc w/stent & us", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7537", "type": "HCPCS" } ], "description": "Insrt atril pm w/l vent lead", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7538", "type": "HCPCS" } ], "description": "Insrt vent pm w/l vent lead", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7539", "type": "HCPCS" } ], "description": "Insrt a & v pm w/l vent lead", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7540", "type": "HCPCS" } ], "description": "Rmv&rplc pm dul w/l vnt lead", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7541", "type": "HCPCS" } ], "description": "Ercp w/ pancreatoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7542", "type": "HCPCS" } ], "description": "Ercp w/bx & pancreatoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7543", "type": "HCPCS" } ], "description": "Ercp w/otomy, pancreatoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7544", "type": "HCPCS" } ], "description": "Ercp rmv calc pancreatoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7545", "type": "HCPCS" } ], "description": "Exch bil cath w/ rmv calculi", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7546", "type": "HCPCS" } ], "description": "Rep nph/urt cath w/dil stric", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7547", "type": "HCPCS" } ], "description": "Cnvrt neph cath w/ dil stric", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7548", "type": "HCPCS" } ], "description": "Exch neph cath w/ dil stric", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7549", "type": "HCPCS" } ], "description": "Chge urtr stent w/ dil stric", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7550", "type": "HCPCS" } ], "description": "Cysto w/ bx(s) w/ blue light", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7551", "type": "HCPCS" } ], "description": "Exc neuroma w/ implnt nv end", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7552", "type": "HCPCS" } ], "description": "R hrt art/grft ang hrt flow", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7553", "type": "HCPCS" } ], "description": "R&l hrt art/vent ang drg ad", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7554", "type": "HCPCS" } ], "description": "Cystureth blu li cyst fl img", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7555", "type": "HCPCS" } ], "description": "Rmvl thyrd w/autotran parath", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9600", "type": "HCPCS" } ], "description": "Perc drug-el cor stent sing", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9602", "type": "HCPCS" } ], "description": "Perc d-e cor stent ather s", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9604", "type": "HCPCS" } ], "description": "Perc d-e cor revasc t cabg s", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9606", "type": "HCPCS" } ], "description": "Perc d-e cor revasc w AMI s", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9607", "type": "HCPCS" } ], "description": "Perc d-e cor revasc chro sin", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9728", "type": "HCPCS" } ], "description": "Place device/marker, non pro", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1334.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1334.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9734", "type": "HCPCS" } ], "description": "U/s trtmt, not leiomyomata", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9739", "type": "HCPCS" } ], "description": "Cystoscopy prostatic imp 1-3", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9740", "type": "HCPCS" } ], "description": "Cysto impl 4 or more", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9751", "type": "HCPCS" } ], "description": "Microwave bronch, 3d, ebus", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9757", "type": "HCPCS" } ], "description": "Spine/lumbar disk surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9758", "type": "HCPCS" } ], "description": "Interatrial shunt IDE", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 16516.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16516.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9760", "type": "HCPCS" } ], "description": "Non-blind interatrial shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 25954.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25954.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9761", "type": "HCPCS" } ], "description": "Cysto, litho, vacuum kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9764", "type": "HCPCS" } ], "description": "Revasc intravasc lithotripsy", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9765", "type": "HCPCS" } ], "description": "Revasc intra lithotrip-stent", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9766", "type": "HCPCS" } ], "description": "Revasc intra lithotrip-ather", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9767", "type": "HCPCS" } ], "description": "Revasc lithotrip-stent-ather", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9769", "type": "HCPCS" } ], "description": "Cysto w/temp pros implant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9772", "type": "HCPCS" } ], "description": "Revasc lithotrip tibi/perone", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9773", "type": "HCPCS" } ], "description": "Revasc lithotr-stent tib/per", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9774", "type": "HCPCS" } ], "description": "Revasc lithotr-ather tib/per", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9775", "type": "HCPCS" } ], "description": "Revasc lith-sten-ath tib/per", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9778", "type": "HCPCS" } ], "description": "Colpopexy, min/inv, ex-perit", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9779", "type": "HCPCS" } ], "description": "ESD endoscopy or colonoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9780", "type": "HCPCS" } ], "description": "Insert cv cath inf & sup app", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7786.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7786.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9781", "type": "HCPCS" } ], "description": "Arthro/shoul surg; w/spacer", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9782", "type": "HCPCS" } ], "description": "Blind myocar trpl bon marrow", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 16516.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16516.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9783", "type": "HCPCS" } ], "description": "Blind cor sinus reducer impl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0104", "type": "HCPCS" } ], "description": "CA screen;flexi sigmoidscope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0105", "type": "HCPCS" } ], "description": "Colorectal scrn; hi risk ind", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0121", "type": "HCPCS" } ], "description": "Colon ca scrn not hi rsk ind", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0213T", "type": "HCPCS" } ], "description": "Njx paravert w/us cer/thor", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0216T", "type": "HCPCS" } ], "description": "Njx paravert w/us lumb/sac", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0219T", "type": "HCPCS" } ], "description": "Plmt post facet implt cerv", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0260", "type": "HCPCS" } ], "description": "Inj for sacroiliac jt anesth", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0341", "type": "HCPCS" } ], "description": "Percutaneous islet celltrans", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0342", "type": "HCPCS" } ], "description": "Laparoscopy islet cell trans", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0343", "type": "HCPCS" } ], "description": "Laparotomy islet cell transp", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0412", "type": "HCPCS" } ], "description": "Open tx iliac spine uni/bil", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0413", "type": "HCPCS" } ], "description": "Pelvic ring fracture uni/bil", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0414", "type": "HCPCS" } ], "description": "Pelvic ring fx treat int fix", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0415", "type": "HCPCS" } ], "description": "Open tx post pelvic fxcture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0448", "type": "HCPCS" } ], "description": "Place perm pacing cardiovert", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0516", "type": "HCPCS" } ], "description": "Insert drug del implant, >4", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0517", "type": "HCPCS" } ], "description": "Remove drug implant", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0518", "type": "HCPCS" } ], "description": "Remove w insert drug implant", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9615", "type": "HCPCS" } ], "description": "Inj, pegulicianine, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 101.65, "minimum": 37.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 82.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 82.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9173", "type": "HCPCS" } ], "description": "Inj, nypozi, 1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.46, "minimum": 1.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0601", "type": "HCPCS" } ], "description": "Sevelamer carbonate 20 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.3, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0602", "type": "HCPCS" } ], "description": "Sevelamer carbonate pdr 20mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.81, "minimum": 0.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0603", "type": "HCPCS" } ], "description": "Sevelamer hydrochloride 20mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.54, "minimum": 0.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0605", "type": "HCPCS" } ], "description": "Sucroferric oxyhydroxide 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.57, "minimum": 0.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82045", "type": "HCPCS" } ], "description": "Albumin ischemia modified", "standard_charges": [ { "billing_class": "facility", "maximum": 127.28, "minimum": 33.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82044", "type": "HCPCS" } ], "description": "Microalbumin semiquant", "standard_charges": [ { "billing_class": "facility", "maximum": 23.36, "minimum": 6.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82043", "type": "HCPCS" } ], "description": "Microalbumin quantitative", "standard_charges": [ { "billing_class": "facility", "maximum": 21.68, "minimum": 5.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82042", "type": "HCPCS" } ], "description": "Assay of urine albumin", "standard_charges": [ { "billing_class": "facility", "maximum": 29.18, "minimum": 7.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82040", "type": "HCPCS" } ], "description": "Assay of serum albumin", "standard_charges": [ { "billing_class": "facility", "maximum": 18.56, "minimum": 4.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82030", "type": "HCPCS" } ], "description": "Assay of adp & amp", "standard_charges": [ { "billing_class": "facility", "maximum": 96.75, "minimum": 25.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 96.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 96.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82024", "type": "HCPCS" } ], "description": "Assay of acth", "standard_charges": [ { "billing_class": "facility", "maximum": 144.83, "minimum": 38.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82017", "type": "HCPCS" } ], "description": "Acylcarnitines quant", "standard_charges": [ { "billing_class": "facility", "maximum": 63.26, "minimum": 16.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82016", "type": "HCPCS" } ], "description": "Acylcarnitines qual", "standard_charges": [ { "billing_class": "facility", "maximum": 61.84, "minimum": 16.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82013", "type": "HCPCS" } ], "description": "Acetylcholinesterase assay", "standard_charges": [ { "billing_class": "facility", "maximum": 46.09, "minimum": 12.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82010", "type": "HCPCS" } ], "description": "Acetone assay", "standard_charges": [ { "billing_class": "facility", "maximum": 30.64, "minimum": 8.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82009", "type": "HCPCS" } ], "description": "Test for acetone/ketones", "standard_charges": [ { "billing_class": "facility", "maximum": 16.95, "minimum": 4.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81596", "type": "HCPCS" } ], "description": "Nfct ds chrnc hcv 6 assays", "standard_charges": [ { "billing_class": "facility", "maximum": 270.71, "minimum": 72.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 72.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 270.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 270.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81595", "type": "HCPCS" } ], "description": "Cardiology hrt trnspl mrna", "standard_charges": [ { "billing_class": "facility", "maximum": 12150.0, "minimum": 3240.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3240.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12150.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12150.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81560", "type": "HCPCS" } ], "description": "Trnsplj pd lvr&bwl cd154+cll", "standard_charges": [ { "billing_class": "facility", "maximum": 2402.74, "minimum": 640.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 640.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2402.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2402.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81554", "type": "HCPCS" } ], "description": "Pulm ds ipf mrna 190 gen alg", "standard_charges": [ { "billing_class": "facility", "maximum": 20700.0, "minimum": 5409.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5409.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20700.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20700.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81552", "type": "HCPCS" } ], "description": "Onc uveal mlnma mrna 15 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 29160.0, "minimum": 7776.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7776.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29160.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29160.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81551", "type": "HCPCS" } ], "description": "Onc prostate 3 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 7612.5, "minimum": 2030.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2030.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7612.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7612.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81546", "type": "HCPCS" } ], "description": "Onc thyr mrna 10,196 gen alg", "standard_charges": [ { "billing_class": "facility", "maximum": 13500.0, "minimum": 3600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81542", "type": "HCPCS" } ], "description": "Onc prostate mrna 22 cnt gen", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81541", "type": "HCPCS" } ], "description": "Onc prostate mrna 46 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81540", "type": "HCPCS" } ], "description": "Oncology tum unknown origin", "standard_charges": [ { "billing_class": "facility", "maximum": 14062.5, "minimum": 3750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14062.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14062.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81539", "type": "HCPCS" } ], "description": "Oncology prostate prob score", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81538", "type": "HCPCS" } ], "description": "Oncology lung", "standard_charges": [ { "billing_class": "facility", "maximum": 10766.25, "minimum": 2871.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2871.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10766.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10766.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81536", "type": "HCPCS" } ], "description": "Oncology gynecologic", "standard_charges": [ { "billing_class": "facility", "maximum": 665.85, "minimum": 177.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 177.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 665.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 665.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81535", "type": "HCPCS" } ], "description": "Oncology gynecologic", "standard_charges": [ { "billing_class": "facility", "maximum": 2172.98, "minimum": 579.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 579.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2172.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2172.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81529", "type": "HCPCS" } ], "description": "Onc cutan mlnma mrna 31 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 26973.75, "minimum": 7193.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7193.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26973.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26973.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81528", "type": "HCPCS" } ], "description": "Oncology colorectal scr", "standard_charges": [ { "billing_class": "facility", "maximum": 1908.26, "minimum": 508.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 508.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1908.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1908.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81525", "type": "HCPCS" } ], "description": "Oncology colon mrna", "standard_charges": [ { "billing_class": "facility", "maximum": 11685.0, "minimum": 3116.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3116.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11685.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81523", "type": "HCPCS" } ], "description": "Onc brst mrna 70 cnt 31 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0607", "type": "HCPCS" } ], "description": "Lanthanum carbonate oral 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.24, "minimum": 0.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0608", "type": "HCPCS" } ], "description": "Lanthanum carbonate pwdr 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.22, "minimum": 0.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0609", "type": "HCPCS" } ], "description": "Ferric citrate orl 3 mg iron", "standard_charges": [ { "billing_class": "facility", "maximum": 0.26, "minimum": 0.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0615", "type": "HCPCS" } ], "description": "Calcium acetate, oral, 23 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.08, "minimum": 0.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0666", "type": "HCPCS" } ], "description": "Inj, bupivacaine liposome", "standard_charges": [ { "billing_class": "facility", "maximum": 3.93, "minimum": 1.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0870", "type": "HCPCS" } ], "description": "Injection, imetelstat, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 150.32, "minimum": 57.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 123.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 123.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 150.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 150.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0901", "type": "HCPCS" } ], "description": "Vadadustat oral 1mg for esrd", "standard_charges": [ { "billing_class": "facility", "maximum": 0.46, "minimum": 0.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1307", "type": "HCPCS" } ], "description": "Inj, crovalimab-akkz, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1452.29, "minimum": 551.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 551.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1217.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1217.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1452.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1452.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1414", "type": "HCPCS" } ], "description": "Inj, beqvez, per tx dose", "standard_charges": [ { "billing_class": "facility", "maximum": 10054100.0, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10054100.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10054100.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1552", "type": "HCPCS" } ], "description": "Inj, alyglo, 500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 398.07, "minimum": 130.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 130.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 343.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 343.72 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 249.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 398.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 398.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2290", "type": "HCPCS" } ], "description": "Inj, nafcillin sodium, 20 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.76, "minimum": 0.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2472", "type": "HCPCS" } ], "description": "Inj, pantoprazole sodium chl", "standard_charges": [ { "billing_class": "facility", "maximum": 25.96, "minimum": 20.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2802", "type": "HCPCS" } ], "description": "Inj, romiplostim 1 microgram", "standard_charges": [ { "billing_class": "facility", "maximum": 28.56, "minimum": 11.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3392", "type": "HCPCS" } ], "description": "Inj, exagamglogene autotem", "standard_charges": [ { "billing_class": "facility", "maximum": 6319720.0, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2332000.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6319720.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6319720.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7514", "type": "HCPCS" } ], "description": "Mycophenol (myhibbin) 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 7.1, "minimum": 5.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7601", "type": "HCPCS" } ], "description": "Ensifentrine inh 3 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 159.89, "minimum": 115.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 115.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 115.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 159.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 159.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9026", "type": "HCPCS" } ], "description": "Inj, tarlatamab-dlle, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4269.39, "minimum": 1564.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1564.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3510.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3510.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4269.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4269.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9028", "type": "HCPCS" } ], "description": "Inj, nogapendekin pmln, 1mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 257.1, "minimum": 94.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 222.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 222.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 161.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 257.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 257.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9076", "type": "HCPCS" } ], "description": "Inj, cyclophos (baxter) 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 15.75, "minimum": 5.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9292", "type": "HCPCS" } ], "description": "Inj, pemetrexed (avyxa) 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 256.91, "minimum": 82.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 82.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 184.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 184.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 256.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 256.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0155", "type": "HCPCS" } ], "description": "Dronabinol (syndros) 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 10.54, "minimum": 7.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5142", "type": "HCPCS" } ], "description": "Inj adalimumab-ryvk, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 30.37, "minimum": 28.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 30.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5144", "type": "HCPCS" } ], "description": "Inj, idacio, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 52.6, "minimum": 40.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 52.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5146", "type": "HCPCS" } ], "description": "Inj, hercessi, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 286.85, "minimum": 40.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 206.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 206.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 286.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 286.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90281", "type": "HCPCS" } ], "description": "Human ig im", "standard_charges": [ { "billing_class": "facility", "maximum": 222.49, "minimum": 161.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 222.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 222.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 161.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 161.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90283", "type": "HCPCS" } ], "description": "Human ig iv", "standard_charges": [ { "billing_class": "facility", "maximum": 247.91, "minimum": 123.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 123.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 123.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 247.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 247.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90284", "type": "HCPCS" } ], "description": "Human ig sc", "standard_charges": [ { "billing_class": "facility", "maximum": 62.33, "minimum": 34.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 34.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90291", "type": "HCPCS" } ], "description": "Cmv ig iv", "standard_charges": [ { "billing_class": "facility", "maximum": 5713.28, "minimum": 4111.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4111.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4111.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5713.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5713.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90371", "type": "HCPCS" } ], "description": "Hep b ig im", "standard_charges": [ { "billing_class": "facility", "maximum": 396.5, "minimum": 134.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 134.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 342.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 342.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 248.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 396.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 396.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90375", "type": "HCPCS" } ], "description": "Rabies ig im/sc", "standard_charges": [ { "billing_class": "facility", "maximum": 759.8, "minimum": 279.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 279.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 656.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 656.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 476.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 759.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 759.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90376", "type": "HCPCS" } ], "description": "Rabies ig heat treated", "standard_charges": [ { "billing_class": "facility", "maximum": 1059.01, "minimum": 352.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 352.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1059.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1059.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 941.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 941.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90377", "type": "HCPCS" } ], "description": "Rabies ig ht&sol human im/sc", "standard_charges": [ { "billing_class": "facility", "maximum": 678.91, "minimum": 222.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 222.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 586.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 586.22 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 425.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 678.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 678.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90378", "type": "HCPCS" } ], "description": "Rsv mab im 50mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4260.34, "minimum": 436.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 436.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4260.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4260.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1950.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1950.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90380", "type": "HCPCS" } ], "description": "Rsv monoc antb seasn .5ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 3380.45, "minimum": 1216.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1216.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1216.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3380.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3380.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90381", "type": "HCPCS" } ], "description": "Rsv monoc antb seasnl 1ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.23, "minimum": 1216.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1216.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1216.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90384", "type": "HCPCS" } ], "description": "Rh ig full-dose im", "standard_charges": [ { "billing_class": "facility", "maximum": 324.66, "minimum": 193.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 193.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 193.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 324.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 324.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90385", "type": "HCPCS" } ], "description": "Rh ig minidose im", "standard_charges": [ { "billing_class": "facility", "maximum": 163.3, "minimum": 69.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 80.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 69.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 163.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 163.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90386", "type": "HCPCS" } ], "description": "Rh ig iv", "standard_charges": [ { "billing_class": "facility", "maximum": 1796.0, "minimum": 23.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 23.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1796.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1796.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90389", "type": "HCPCS" } ], "description": "Tetanus ig im", "standard_charges": [ { "billing_class": "facility", "maximum": 2111.09, "minimum": 1519.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1519.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1519.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2111.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2111.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90396", "type": "HCPCS" } ], "description": "Varicella-zoster ig im", "standard_charges": [ { "billing_class": "facility", "maximum": 6103.68, "minimum": 2361.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2361.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5107.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5107.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6103.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6103.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90581", "type": "HCPCS" } ], "description": "Anthrax vaccine sc or im", "standard_charges": [ { "billing_class": "facility", "maximum": 314.52, "minimum": 231.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 231.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 231.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 314.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 314.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90585", "type": "HCPCS" } ], "description": "Bcg vaccine percut", "standard_charges": [ { "billing_class": "facility", "maximum": 552.46, "minimum": 397.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 397.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 397.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 552.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 552.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90586", "type": "HCPCS" } ], "description": "Bcg vaccine intravesical", "standard_charges": [ { "billing_class": "facility", "maximum": 406.36, "minimum": 254.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 350.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 350.88 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 254.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 406.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 406.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90587", "type": "HCPCS" } ], "description": "Dengue vacc quad 3 dose subq", "standard_charges": [ { "billing_class": "facility", "maximum": 214.63, "minimum": 154.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 154.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 154.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 214.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 214.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90589", "type": "HCPCS" } ], "description": "Chikungunya vaccine live im", "standard_charges": [ { "billing_class": "facility", "maximum": 643.5, "minimum": 643.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 643.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 643.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90611", "type": "HCPCS" } ], "description": "Smallpox&monkeypox vac 0.5ml", "standard_charges": [ { "billing_class": "facility", "maximum": 631.8, "minimum": 0.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 631.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 631.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90619", "type": "HCPCS" } ], "description": "Menacwy-tt vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 558.83, "minimum": 402.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 402.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 402.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 558.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 558.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90620", "type": "HCPCS" } ], "description": "Menb rp w/omv vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 675.2, "minimum": 523.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 523.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 523.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 675.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 675.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90621", "type": "HCPCS" } ], "description": "Menb rlp vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 618.31, "minimum": 445.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 445.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 445.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 618.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 618.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90622", "type": "HCPCS" } ], "description": "Vaccinia vrs vac 0.3 ml perq", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90623", "type": "HCPCS" } ], "description": "Menacwy-tt menb-fhbp vacc im", "standard_charges": [ { "billing_class": "facility", "maximum": 747.96, "minimum": 539.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 539.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 539.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 747.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 747.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90625", "type": "HCPCS" } ], "description": "Cholera vaccine live oral", "standard_charges": [ { "billing_class": "facility", "maximum": 643.5, "minimum": 643.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 643.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 643.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90626", "type": "HCPCS" } ], "description": "Tic-brn enceph vac 0.25ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 677.27, "minimum": 677.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 677.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 677.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90627", "type": "HCPCS" } ], "description": "Tic-brn enceph vac 0.5ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 677.27, "minimum": 677.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 677.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 677.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90632", "type": "HCPCS" } ], "description": "Hepa vaccine adult im", "standard_charges": [ { "billing_class": "facility", "maximum": 194.06, "minimum": 121.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 167.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 167.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 121.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 194.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 194.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90633", "type": "HCPCS" } ], "description": "Hepa vacc ped/adol 2 dose im", "standard_charges": [ { "billing_class": "facility", "maximum": 113.77, "minimum": 88.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 88.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 88.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 113.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90636", "type": "HCPCS" } ], "description": "Hep a/hep b vacc adult im", "standard_charges": [ { "billing_class": "facility", "maximum": 350.48, "minimum": 295.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 295.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 295.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 350.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 350.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90644", "type": "HCPCS" } ], "description": "Hib-mency vacc 6wk-18m0 im", "standard_charges": [ { "billing_class": "facility", "maximum": 59.62, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90647", "type": "HCPCS" } ], "description": "Hib prp-omp vacc 3 dose im", "standard_charges": [ { "billing_class": "facility", "maximum": 99.02, "minimum": 71.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90648", "type": "HCPCS" } ], "description": "Hib prp-t vaccine 4 dose im", "standard_charges": [ { "billing_class": "facility", "maximum": 42.22, "minimum": 28.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90649", "type": "HCPCS" } ], "description": "4vhpv vaccine 3 dose im", "standard_charges": [ { "billing_class": "facility", "maximum": 284.9, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 284.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 284.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90650", "type": "HCPCS" } ], "description": "2vhpv vaccine 3 dose im", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90651", "type": "HCPCS" } ], "description": "9vhpv vaccine 3 dose im", "standard_charges": [ { "billing_class": "facility", "maximum": 999.94, "minimum": 719.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 719.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 719.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 999.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 999.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90653", "type": "HCPCS" } ], "description": "Iiv adjuvant vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 226.26, "minimum": 141.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 195.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 195.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 141.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 226.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 226.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81522", "type": "HCPCS" } ], "description": "Onc breast mrna 12 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81521", "type": "HCPCS" } ], "description": "Onc breast mrna 70 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81520", "type": "HCPCS" } ], "description": "Onc breast mrna 58 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 9413.29, "minimum": 2510.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2510.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9413.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9413.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81519", "type": "HCPCS" } ], "description": "Oncology breast mrna", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", 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schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5577.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81508", "type": "HCPCS" } ], "description": "Ftl cgen abnor two proteins", "standard_charges": [ { "billing_class": "facility", "maximum": 203.63, "minimum": 54.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 203.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 203.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81507", "type": "HCPCS" } ], "description": "Fetal aneuploidy trisom risk", 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"methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 258.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 258.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81504", "type": "HCPCS" } ], "description": "Oncology tissue of origin", "standard_charges": [ { "billing_class": "facility", "maximum": 1950.0, "minimum": 520.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1950.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81503", "type": "HCPCS" } ], "description": "Onco (ovar) five proteins", "standard_charges": [ { "billing_class": "facility", "maximum": 3363.75, "minimum": 897.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3363.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3363.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81500", "type": "HCPCS" } ], "description": "Onco (ovar) two proteins", "standard_charges": [ { "billing_class": "facility", "maximum": 976.88, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 976.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 976.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81493", "type": "HCPCS" } ], "description": "Cor artery disease mrna", "standard_charges": [ { "billing_class": "facility", "maximum": 3937.5, "minimum": 1050.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1050.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3937.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3937.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81490", "type": "HCPCS" } ], "description": "Autoimmune rheumatoid arthr", "standard_charges": [ { "billing_class": "facility", "maximum": 3152.44, "minimum": 840.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 840.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3152.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3152.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81471", "type": "HCPCS" } ], "description": "X-linked intellectual dblt", "standard_charges": [ { "billing_class": "facility", "maximum": 3427.5, "minimum": 914.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 914.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3427.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3427.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81470", "type": "HCPCS" } ], "description": "X-linked intellectual dblt", "standard_charges": [ { "billing_class": "facility", "maximum": 3427.5, "minimum": 914.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 914.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3427.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3427.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81465", "type": "HCPCS" } ], "description": "Whole mitochondrial genome", "standard_charges": [ { "billing_class": "facility", "maximum": 3510.0, "minimum": 936.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 936.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3510.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3510.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81460", "type": "HCPCS" } ], "description": "Whole mitochondrial genome", "standard_charges": [ { "billing_class": "facility", "maximum": 4826.25, "minimum": 1287.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1287.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4826.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4826.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81456", "type": "HCPCS" } ], "description": "Tgsap so/hl 51/< rna alys", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81455", "type": "HCPCS" } ], "description": "Targeted genomic seq analys", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81451", "type": "HCPCS" } ], "description": "Tgsap hl neo 5-50 rna alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2848.24, "minimum": 759.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2848.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2848.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81450", "type": "HCPCS" } ], "description": "Targeted genomic seq analys", "standard_charges": [ { "billing_class": "facility", "maximum": 2848.24, "minimum": 759.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2848.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2848.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81449", "type": "HCPCS" } ], "description": "Tgsap so neo 5-50 rna alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2242.16, "minimum": 597.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2242.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2242.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81448", "type": "HCPCS" } ], "description": "Hrdtry perph neurphy panel", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 584.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90655", "type": "HCPCS" } ], "description": "Iiv3 vacc no prsv 0.25 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 34.9, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90656", "type": "HCPCS" } ], "description": "Iiv3 vacc no prsv 0.5 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 60.57, "minimum": 38.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 52.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 38.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90657", "type": "HCPCS" } ], "description": "Iiv3 vaccine splt 0.25 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 29.62, "minimum": 18.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 25.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 18.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90658", "type": "HCPCS" } ], "description": "Iiv3 vaccine splt 0.5 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 59.24, "minimum": 37.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 51.15 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 37.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90660", "type": "HCPCS" } ], "description": "Laiv3 vaccine intranasal", "standard_charges": [ { "billing_class": "facility", "maximum": 78.24, "minimum": 49.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67.56 }, { 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Traditional", "standard_charge_dollar": 86.23 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 62.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90662", "type": "HCPCS" } ], "description": "Iiv no prsv increased ag im", "standard_charges": [ { "billing_class": "facility", "maximum": 226.26, "minimum": 141.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 195.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 195.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 141.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 226.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 226.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90670", "type": "HCPCS" } ], "description": "Pcv13 vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 699.15, "minimum": 438.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 603.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 603.7 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 438.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 699.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 699.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90671", "type": "HCPCS" } ], "description": "Pcv15 vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 687.15, "minimum": 431.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 593.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 593.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 431.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 687.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 687.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90672", "type": "HCPCS" } ], "description": "Laiv4 vaccine intranasal", "standard_charges": [ { "billing_class": "facility", "maximum": 82.36, "minimum": 57.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 57.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90673", "type": "HCPCS" } ], "description": "Riv3 vaccine no preserv im", "standard_charges": [ { "billing_class": "facility", "maximum": 226.26, "minimum": 141.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 195.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 195.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 141.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 226.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 226.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90674", "type": "HCPCS" } ], "description": "Cciiv4 vac no prsv 0.5 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 70.43, "minimum": 70.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 70.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90675", "type": "HCPCS" } ], "description": "Rabies vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 888.28, "minimum": 313.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 313.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 767.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 767.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 557.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 888.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 888.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90677", "type": "HCPCS" } ], "description": "Pcv20 vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 807.69, "minimum": 506.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 697.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 697.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 506.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 807.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 807.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90678", "type": "HCPCS" } ], "description": "Rsv vacc pref bivalent im", "standard_charges": [ { "billing_class": "facility", "maximum": 959.34, "minimum": 690.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 690.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 690.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 959.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 959.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90679", "type": "HCPCS" } ], "description": "Rsv vacc pref recomb adjt im", "standard_charges": [ { "billing_class": "facility", "maximum": 956.09, "minimum": 687.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 687.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 687.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 956.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 956.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90680", "type": "HCPCS" } ], "description": "Rv5 vacc 3 dose live oral", "standard_charges": [ { "billing_class": "facility", "maximum": 320.95, "minimum": 231.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 231.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 231.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 320.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 320.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90681", "type": "HCPCS" } ], "description": "Rv1 vacc 2 dose live oral", "standard_charges": [ { "billing_class": "facility", "maximum": 324.65, "minimum": 300.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 324.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 324.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 300.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 300.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90682", "type": "HCPCS" } ], "description": "Riv4 vacc recombinant dna im", "standard_charges": [ { "billing_class": "facility", "maximum": 150.95, "minimum": 150.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 150.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 150.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90683", "type": "HCPCS" } ], "description": "Rsv vacc mrna lipid nano im", "standard_charges": [ { "billing_class": "facility", "maximum": 943.08, "minimum": 678.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 678.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 678.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 943.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 943.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90684", "type": "HCPCS" } ], "description": "Pcv21 vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 888.58, "minimum": 557.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 767.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 767.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 557.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 888.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 888.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90685", "type": "HCPCS" } ], "description": "Iiv4 vacc no prsv 0.25 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 44.72, "minimum": 44.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 44.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90686", "type": "HCPCS" } ], "description": "Iiv4 vacc no prsv 0.5 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 46.17, "minimum": 46.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 46.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90687", "type": "HCPCS" } ], "description": "Iiv4 vaccine splt 0.25 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 21.57, "minimum": 21.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 21.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90688", "type": "HCPCS" } ], "description": "Iiv4 vaccine splt 0.5 ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 43.15, "minimum": 43.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 43.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 43.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90690", "type": "HCPCS" } ], "description": "Typhoid vaccine oral", "standard_charges": [ { "billing_class": "facility", "maximum": 249.61, "minimum": 244.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 249.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 249.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 244.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 244.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90691", "type": "HCPCS" } ], "description": "Typhoid vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 342.97, "minimum": 320.19, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 342.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 342.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 320.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 320.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90694", "type": "HCPCS" } ], "description": "Vacc aiiv4 no prsrv 0.5ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 159.07, "minimum": 159.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 159.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 159.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90696", "type": "HCPCS" } ], "description": "Dtap-ipv vaccine 4-6 yrs im", "standard_charges": [ { "billing_class": "facility", "maximum": 413.46, "minimum": 142.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 142.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 142.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 413.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 413.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90697", "type": "HCPCS" } ], "description": "Dtap-ipv-hib-hepb vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 1014.05, "minimum": 366.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 366.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 366.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1014.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1014.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90698", "type": "HCPCS" } ], "description": "Dtap-ipv/hib vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 365.82, "minimum": 280.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 280.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 280.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 365.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 365.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90700", "type": "HCPCS" } ], "description": "Dtap vaccine < 7 yrs im", "standard_charges": [ { "billing_class": "facility", "maximum": 95.88, "minimum": 67.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 67.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81445", "type": "HCPCS" } ], "description": "Targeted genomic seq analys", "standard_charges": [ { "billing_class": "facility", "maximum": 2242.16, "minimum": 597.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2242.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2242.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81443", "type": "HCPCS" } ], "description": "Genetic tstg severe inh cond", "standard_charges": [ { "billing_class": "facility", "maximum": 9182.1, "minimum": 2448.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2448.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9182.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9182.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81442", "type": "HCPCS" } ], "description": "Noonan spectrum disorders", "standard_charges": [ { "billing_class": "facility", "maximum": 8038.5, "minimum": 2143.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2143.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8038.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8038.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81441", "type": "HCPCS" } ], "description": "Ibmfs seq alys pnl 30 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 9182.1, "minimum": 2448.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2448.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9182.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9182.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81440", "type": "HCPCS" } ], "description": "Mitochondrial gene", "standard_charges": [ { "billing_class": "facility", "maximum": 12465.0, "minimum": 3324.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3324.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12465.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12465.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81439", "type": "HCPCS" } ], "description": "Inherited cardmypthy 5 gns", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 584.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81438", "type": "HCPCS" } ], "description": "Heredtry nurondcrn tum dsrdr", "standard_charges": [ { "billing_class": "facility", "maximum": 1645.99, "minimum": 1645.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1645.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1645.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81437", "type": "HCPCS" } ], "description": "Heredtry nurondcrn tum dsrdr", "standard_charges": [ { "billing_class": "facility", "maximum": 1645.99, "minimum": 1303.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1303.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1645.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1645.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81436", "type": "HCPCS" } ], "description": "Hereditary colon ca dsordrs", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 2193.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81435", "type": "HCPCS" } ], "description": "Hereditary colon ca dsordrs", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 1303.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1303.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81434", "type": "HCPCS" } ], "description": "Hereditary retinal disorders", "standard_charges": [ { "billing_class": "facility", "maximum": 2242.16, "minimum": 597.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2242.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2242.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81433", "type": "HCPCS" } ], "description": "Hrdtry brst ca-rlatd dsordrs", "standard_charges": [ { "billing_class": "facility", "maximum": 1645.99, "minimum": 1645.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1645.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1645.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81432", "type": "HCPCS" } ], "description": "Hrdtry brst ca-rlatd dsordrs", "standard_charges": [ { "billing_class": "facility", "maximum": 2546.44, "minimum": 1303.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1303.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2546.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2546.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81431", "type": "HCPCS" } ], "description": "Hearing loss dup/del analys", "standard_charges": [ { "billing_class": "facility", "maximum": 2548.39, "minimum": 679.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 679.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2548.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2548.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81430", "type": "HCPCS" } ], "description": "Hearing loss sequence analys", "standard_charges": [ { "billing_class": "facility", "maximum": 6093.75, "minimum": 1625.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1625.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6093.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6093.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81427", "type": "HCPCS" } ], "description": "Genome re-evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 8766.19, "minimum": 2337.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2337.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8766.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8766.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85175", "type": "HCPCS" } ], "description": "Blood clot lysis time", "standard_charges": [ { "billing_class": "facility", "maximum": 76.39, "minimum": 20.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85210", "type": "HCPCS" } ], "description": "Clot factor ii prothrom spec", "standard_charges": [ { "billing_class": "facility", "maximum": 48.68, "minimum": 12.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85220", "type": "HCPCS" } ], "description": "Blooc clot factor v test", "standard_charges": [ { "billing_class": "facility", "maximum": 66.19, "minimum": 17.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85230", "type": "HCPCS" } ], "description": "Clot factor vii proconvertin", "standard_charges": [ { "billing_class": "facility", "maximum": 67.13, "minimum": 17.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85240", "type": "HCPCS" } ], "description": "Clot factor viii ahg 1 stage", "standard_charges": [ { "billing_class": "facility", "maximum": 67.13, "minimum": 17.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85244", "type": "HCPCS" } ], "description": "Clot factor viii reltd antgn", "standard_charges": [ { "billing_class": "facility", "maximum": 76.58, "minimum": 20.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85245", "type": "HCPCS" } ], "description": "Clot factor viii vw ristoctn", "standard_charges": [ { "billing_class": "facility", "maximum": 86.03, "minimum": 22.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85246", "type": "HCPCS" } ], "description": "Clot factor viii vw antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 86.03, "minimum": 22.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85247", "type": "HCPCS" } ], "description": "Clot factor viii multimetric", "standard_charges": [ { "billing_class": "facility", "maximum": 86.03, "minimum": 22.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85250", "type": "HCPCS" } ], "description": "Clot factor ix ptc/chrstmas", "standard_charges": [ { "billing_class": "facility", "maximum": 71.4, "minimum": 19.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85260", "type": "HCPCS" } ], "description": "Clot factor x stuart-power", "standard_charges": [ { "billing_class": "facility", "maximum": 67.13, "minimum": 17.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85270", "type": "HCPCS" } ], "description": "Clot factor xi pta", "standard_charges": [ { "billing_class": "facility", "maximum": 67.13, "minimum": 17.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85280", "type": "HCPCS" } ], "description": "Clot factor xii hageman", "standard_charges": [ { "billing_class": "facility", "maximum": 72.56, "minimum": 19.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85290", "type": "HCPCS" } ], "description": "Clot factor xiii fibrin stab", "standard_charges": [ { "billing_class": "facility", "maximum": 61.28, "minimum": 16.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90702", "type": "HCPCS" } ], "description": "Dt vaccine under 7 yrs im", "standard_charges": [ { "billing_class": "facility", "maximum": 154.65, "minimum": 45.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 154.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 154.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90707", "type": "HCPCS" } ], "description": "Mmr vaccine sc", "standard_charges": [ { "billing_class": "facility", "maximum": 303.98, "minimum": 216.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 216.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 216.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 303.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 303.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90710", "type": "HCPCS" } ], "description": "Mmrv vaccine sc", "standard_charges": [ { "billing_class": "facility", "maximum": 902.94, "minimum": 650.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 650.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 650.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 902.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 902.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90713", "type": "HCPCS" } ], "description": "Poliovirus ipv sc/im", "standard_charges": [ { "billing_class": "facility", "maximum": 145.07, "minimum": 104.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 104.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 104.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 145.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 145.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90714", "type": "HCPCS" } ], "description": "Td vacc no presv 7 yrs+ im", "standard_charges": [ { "billing_class": "facility", "maximum": 90.73, "minimum": 56.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 78.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 78.34 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 56.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90715", "type": "HCPCS" } ], "description": "Tdap vaccine 7 yrs/> im", "standard_charges": [ { "billing_class": "facility", "maximum": 104.69, "minimum": 65.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 90.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 90.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 65.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 104.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90716", "type": "HCPCS" } ], "description": "Var vaccine live subq", "standard_charges": [ { "billing_class": "facility", "maximum": 594.71, "minimum": 428.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 428.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 428.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 594.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 594.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90717", "type": "HCPCS" } ], "description": "Yellow fever vaccine subq", "standard_charges": [ { "billing_class": "facility", "maximum": 524.09, "minimum": 478.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 524.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 524.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 478.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 478.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90723", "type": "HCPCS" } ], "description": "Dtap-hep b-ipv vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 308.43, "minimum": 229.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 229.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 229.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 308.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 308.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90732", "type": "HCPCS" } ], "description": "Ppsv23 vacc 2 yrs+ subq/im", "standard_charges": [ { "billing_class": "facility", "maximum": 361.7, "minimum": 226.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 312.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 312.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 226.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 361.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 361.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90733", "type": "HCPCS" } ], "description": "Mpsv4 vaccine subq", "standard_charges": [ { "billing_class": "facility", "maximum": 225.28, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 225.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 225.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90734", "type": "HCPCS" } ], "description": "Mcv4 menacwy vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 492.65, "minimum": 368.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 368.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 368.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 492.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 492.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90736", "type": "HCPCS" } ], "description": "Hzv vaccine live subq", "standard_charges": [ { "billing_class": "facility", "maximum": 360.27, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 360.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 360.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90738", "type": "HCPCS" } ], "description": "Inactivated je vacc im", "standard_charges": [ { "billing_class": "facility", "maximum": 828.47, "minimum": 672.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 672.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 672.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 828.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 828.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90739", "type": "HCPCS" } ], "description": "Hepb vacc 2 dose adult im", "standard_charges": [ { "billing_class": "facility", "maximum": 456.09, "minimum": 286.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 393.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 393.82 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 286.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 456.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 456.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90740", "type": "HCPCS" } ], "description": "Hepb vacc 3 dose immunsup im", "standard_charges": [ { "billing_class": "facility", "maximum": 428.59, "minimum": 268.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 370.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 370.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 268.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 428.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 428.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90743", "type": "HCPCS" } ], "description": "Hepb vacc 2 dose adolesc im", "standard_charges": [ { "billing_class": "facility", "maximum": 203.66, "minimum": 127.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 175.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 175.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 127.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 203.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 203.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90744", "type": "HCPCS" } ], "description": "Hepb vacc 3 dose ped/adol im", "standard_charges": [ { "billing_class": "facility", "maximum": 83.39, "minimum": 52.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 72.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 72.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 52.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90746", "type": "HCPCS" } ], "description": "Hepb vaccine 3 dose adult im", "standard_charges": [ { "billing_class": "facility", "maximum": 190.73, "minimum": 119.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 164.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 164.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 119.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 190.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 190.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90747", "type": "HCPCS" } ], "description": "Hepb vacc 4 dose immunsup im", "standard_charges": [ { "billing_class": "facility", "maximum": 381.43, "minimum": 239.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 329.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 329.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 239.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 381.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 381.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90748", "type": "HCPCS" } ], "description": "Hib-hepb vaccine im", "standard_charges": [ { "billing_class": "facility", "maximum": 125.36, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 125.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 125.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90750", "type": "HCPCS" } ], "description": "Hzv vacc recombinant im njx", "standard_charges": [ { "billing_class": "facility", "maximum": 463.09, "minimum": 463.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 463.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 463.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90756", "type": "HCPCS" } ], "description": "Cciiv4 vacc abx free im", "standard_charges": [ { "billing_class": "facility", "maximum": 66.74, "minimum": 66.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 66.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 66.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90759", "type": "HCPCS" } ], "description": "Hep b vac 3ag 10mcg 3 dos im", "standard_charges": [ { "billing_class": "facility", "maximum": 200.05, "minimum": 125.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 172.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 172.74 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 125.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 200.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 200.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91304", "type": "HCPCS" } ], "description": "Coronavirus vaccine 5", "standard_charges": [ { "billing_class": "facility", "maximum": 437.77, "minimum": 274.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 378.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 378.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 274.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 437.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 437.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91318", "type": "HCPCS" } ], "description": "Sarscov2 vac 3mcg trs-suc im", "standard_charges": [ { "billing_class": "facility", "maximum": 177.64, "minimum": 111.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 153.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 153.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 111.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 177.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 177.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91319", "type": "HCPCS" } ], "description": "Sarscv2 vac 10mcg trs-suc im", "standard_charges": [ { "billing_class": "facility", "maximum": 237.88, "minimum": 149.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 205.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 205.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 149.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 237.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 237.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91320", "type": "HCPCS" } ], "description": "Sarscv2 vac 30mcg trs-suc im", "standard_charges": [ { "billing_class": "facility", "maximum": 422.49, "minimum": 265.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 364.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 364.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 265.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 422.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 422.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91321", "type": "HCPCS" } ], "description": "Sarscov2 vac 25 mcg/.25ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 398.53, "minimum": 250.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 344.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 344.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 250.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 398.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 398.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91322", "type": "HCPCS" } ], "description": "Sarscov2 vac 50 mcg/0.5ml im", "standard_charges": [ { "billing_class": "facility", "maximum": 438.07, "minimum": 274.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 378.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 378.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 274.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 438.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 438.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A4248", "type": "HCPCS" } ], "description": "Chlorhexidine antisept", "standard_charges": [ { "billing_class": "facility", "maximum": 0.07, "minimum": 0.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A4802", "type": "HCPCS" } ], "description": "Protamine sulfate per 50 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 31.17, "minimum": 31.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 31.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85291", "type": "HCPCS" } ], "description": "Clot factor xiii fibrin scrn", "standard_charges": [ { "billing_class": "facility", "maximum": 34.16, "minimum": 9.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85292", "type": "HCPCS" } ], "description": "Clot factor fletcher fact", "standard_charges": [ { "billing_class": "facility", "maximum": 70.99, "minimum": 18.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85293", "type": "HCPCS" } ], "description": "Clot factor wght kininogen", "standard_charges": [ { "billing_class": "facility", "maximum": 70.99, "minimum": 18.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85300", "type": "HCPCS" } ], "description": "Antithrombin iii activity", "standard_charges": [ { "billing_class": "facility", "maximum": 44.44, "minimum": 11.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85301", "type": "HCPCS" } ], "description": "Antithrombin iii antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 40.54, "minimum": 10.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85302", "type": "HCPCS" } ], "description": "Clot inhibit prot c antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 45.04, "minimum": 12.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85303", "type": "HCPCS" } ], "description": "Clot inhibit prot c activity", "standard_charges": [ { "billing_class": "facility", "maximum": 51.9, "minimum": 13.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85305", "type": "HCPCS" } ], "description": "Clot inhibit prot s total", "standard_charges": [ { "billing_class": "facility", "maximum": 43.54, "minimum": 11.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85306", "type": "HCPCS" } ], "description": "Clot inhibit prot s free", "standard_charges": [ { "billing_class": "facility", "maximum": 57.45, "minimum": 15.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85307", "type": "HCPCS" } ], "description": "Assay Activated Protein C", "standard_charges": [ { "billing_class": "facility", "maximum": 57.45, "minimum": 15.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85335", "type": "HCPCS" } ], "description": "Factor inhibitor test", "standard_charges": [ { "billing_class": "facility", "maximum": 48.26, "minimum": 12.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85337", "type": "HCPCS" } ], "description": "Thrombomodulin", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85345", "type": "HCPCS" } ], "description": "Coagulation time lee & white", "standard_charges": [ { "billing_class": "facility", "maximum": 17.59, "minimum": 4.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85347", "type": "HCPCS" } ], "description": "Coagulation time activated", "standard_charges": [ { "billing_class": "facility", "maximum": 16.05, "minimum": 4.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85348", "type": "HCPCS" } ], "description": "Coagulation time otr method", "standard_charges": [ { "billing_class": "facility", "maximum": 16.84, "minimum": 4.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85360", "type": "HCPCS" } ], "description": "Euglobulin lysis", "standard_charges": [ { "billing_class": "facility", "maximum": 31.54, "minimum": 8.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85362", "type": "HCPCS" } ], "description": "Fibrin degradation products", "standard_charges": [ { "billing_class": "facility", "maximum": 25.84, "minimum": 6.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85366", "type": "HCPCS" } ], "description": "Fibrinogen test", "standard_charges": [ { "billing_class": "facility", "maximum": 301.73, "minimum": 80.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 80.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 301.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 301.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81426", "type": "HCPCS" } ], "description": "Genome sequence analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 10162.31, "minimum": 2709.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2709.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10162.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10162.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81425", "type": "HCPCS" } ], "description": "Genome sequence analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 18867.0, "minimum": 5031.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5031.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18867.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18867.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81422", "type": "HCPCS" } ], "description": "Fetal chrmoml microdeltj", "standard_charges": [ { "billing_class": "facility", "maximum": 2846.44, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2846.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2846.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81420", "type": "HCPCS" } ], "description": "Fetal chrmoml aneuploidy", "standard_charges": [ { "billing_class": "facility", "maximum": 2846.44, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2846.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2846.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81419", "type": "HCPCS" } ], "description": "Epilepsy gen seq alys panel", "standard_charges": [ { "billing_class": "facility", "maximum": 9182.1, "minimum": 2448.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2448.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9182.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9182.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81418", "type": "HCPCS" } ], "description": "Rx metab gen seq alys pnl 6", "standard_charges": [ { "billing_class": "facility", "maximum": 3439.05, "minimum": 917.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 917.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3439.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3439.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81417", "type": "HCPCS" } ], "description": "Exome re-evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 1200.0, "minimum": 320.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 320.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1200.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1200.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81416", "type": "HCPCS" } ], "description": "Exome sequence analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 45000.0, "minimum": 12000.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12000.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45000.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45000.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81415", "type": "HCPCS" } ], "description": "Exome sequence analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 17925.0, "minimum": 4780.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4780.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17925.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17925.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81414", "type": "HCPCS" } ], "description": "Car ion chnnlpath inc 2 gns", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 584.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81413", "type": "HCPCS" } ], "description": "Car ion chnnlpath inc 10 gns", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 584.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81412", "type": "HCPCS" } ], "description": "Ashkenazi jewish assoc dis", "standard_charges": [ { "billing_class": "facility", "maximum": 9182.1, "minimum": 2448.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2448.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9182.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9182.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9155", "type": "HCPCS" } ], "description": "Artificial saliva", "standard_charges": [ { "billing_class": "facility", "maximum": 18.04, "minimum": 18.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9156", "type": "HCPCS" } ], "description": "Oral mucoadhesive per 1 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 5.66, "minimum": 5.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9180", "type": "HCPCS" } ], "description": "Lice treatment, topical", "standard_charges": [ { "billing_class": "facility", "maximum": 2.08, "minimum": 2.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9502", "type": "HCPCS" } ], "description": "Tc99m tetrofosmin", "standard_charges": [ { "billing_class": "facility", "maximum": 427.77, "minimum": 199.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 199.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 199.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 427.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 427.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9503", "type": "HCPCS" } ], "description": "Tc99m medronate", "standard_charges": [ { "billing_class": "facility", "maximum": 160.4, "minimum": 30.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 30.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9505", "type": "HCPCS" } ], "description": "Tl201 thallium", "standard_charges": [ { "billing_class": "facility", "maximum": 116.58, "minimum": 76.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 76.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 76.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 116.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 116.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9506", "type": "HCPCS" } ], "description": "Tc-99m graphite crucible", "standard_charges": [ { "billing_class": "facility", "maximum": 890.51, "minimum": 328.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 328.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 725.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 725.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 890.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 890.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9507", "type": "HCPCS" } ], "description": "In111 capromab", "standard_charges": [ { "billing_class": "facility", "maximum": 3559.83, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1730.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3559.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3559.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9508", "type": "HCPCS" } ], "description": "I131 iodobenguate, dx", "standard_charges": [ { "billing_class": "facility", "maximum": 2792.82, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 953.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2792.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2792.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9509", "type": "HCPCS" } ], "description": "Iodine I-123 sod iodide mil", "standard_charges": [ { "billing_class": "facility", "maximum": 417.26, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 417.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 417.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9510", "type": "HCPCS" } ], "description": "Tc99m disofenin", "standard_charges": [ { "billing_class": "facility", "maximum": 162.17, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 162.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 162.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9512", "type": "HCPCS" } ], "description": "Tc99m pertechnetate", "standard_charges": [ { "billing_class": "facility", "maximum": 33.31, "minimum": 3.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9513", "type": "HCPCS" } ], "description": "Lutetium lu 177 dotatat ther", "standard_charges": [ { "billing_class": "facility", "maximum": 802.84, "minimum": 316.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 316.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 686.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 686.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 802.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 802.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9515", "type": "HCPCS" } ], "description": "Choline c-11", "standard_charges": [ { "billing_class": "facility", "maximum": 11700.0, "minimum": 2516.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2516.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11700.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11700.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5590.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5590.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9516", "type": "HCPCS" } ], "description": "Iodine I-123 sod iodide mic", "standard_charges": [ { "billing_class": "facility", "maximum": 302.44, "minimum": 224.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 224.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 224.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 302.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 302.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9520", "type": "HCPCS" } ], "description": "Tc99 tilmanocept diag 0.5mci", "standard_charges": [ { "billing_class": "facility", "maximum": 1548.07, "minimum": 1548.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1548.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1548.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9521", "type": "HCPCS" } ], "description": "Tc99m exametazime", "standard_charges": [ { "billing_class": "facility", "maximum": 4010.69, "minimum": 927.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 927.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4010.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4010.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2174.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2174.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9526", "type": "HCPCS" } ], "description": "Nitrogen n-13 ammonia", "standard_charges": [ { "billing_class": "facility", "maximum": 1993.37, "minimum": 1542.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1542.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1542.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1993.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1993.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9537", "type": "HCPCS" } ], "description": "Tc99m mebrofenin", "standard_charges": [ { "billing_class": "facility", "maximum": 307.48, "minimum": 132.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 132.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 132.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 307.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 307.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9538", "type": "HCPCS" } ], "description": "Tc99m pyrophosphate", "standard_charges": [ { "billing_class": "facility", "maximum": 149.88, "minimum": 104.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 149.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 149.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 104.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9539", "type": "HCPCS" } ], "description": "Tc99m pentetate", "standard_charges": [ { "billing_class": "facility", "maximum": 68.37, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9540", "type": "HCPCS" } ], "description": "Tc99m maa", "standard_charges": [ { "billing_class": "facility", "maximum": 79.78, "minimum": 70.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 70.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9541", "type": "HCPCS" } ], "description": "Tc99m sulfur colloid", "standard_charges": [ { "billing_class": "facility", "maximum": 2036.29, "minimum": 625.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 625.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 625.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2036.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2036.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9542", "type": "HCPCS" } ], "description": "In111 ibritumomab, dx", "standard_charges": [ { "billing_class": "facility", "maximum": 2162.63, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2162.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2162.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9543", "type": "HCPCS" } ], "description": "Y90 ibritumomab, rx", "standard_charges": [ { "billing_class": "facility", "maximum": 153994.53, "minimum": 56824.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56824.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 151769.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 151769.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 153994.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 153994.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9547", "type": "HCPCS" } ], "description": "In111 oxyquinoline", "standard_charges": [ { "billing_class": "facility", "maximum": 4925.65, "minimum": 831.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 831.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4925.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4925.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2093.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2093.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9548", "type": "HCPCS" } ], "description": "In111 pentetate", "standard_charges": [ { "billing_class": "facility", "maximum": 2072.07, "minimum": 745.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 745.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2072.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2072.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1938.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1938.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9553", "type": "HCPCS" } ], "description": "Cr51 chromate", "standard_charges": [ { "billing_class": "facility", "maximum": 1917.96, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1917.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 880.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 880.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9554", "type": "HCPCS" } ], "description": "I125 iothalamate, dx", "standard_charges": [ { "billing_class": "facility", "maximum": 649.64, "minimum": 87.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 649.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 87.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 87.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 105.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 105.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9556", "type": "HCPCS" } ], "description": "Ga67 gallium", "standard_charges": [ { "billing_class": "facility", "maximum": 59.62, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9557", "type": "HCPCS" } ], "description": "Tc99m bicisate", "standard_charges": [ { "billing_class": "facility", "maximum": 8579.21, "minimum": 775.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 775.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8579.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8579.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1853.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1853.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9558", "type": "HCPCS" } ], "description": "Xe133 xenon 10mci", "standard_charges": [ { "billing_class": "facility", "maximum": 703.03, "minimum": 596.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 596.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 596.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 703.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 703.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81411", "type": "HCPCS" } ], "description": "Aortic dysfunction/dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 5063.21, "minimum": 1350.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1350.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5063.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5063.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81410", "type": "HCPCS" } ], "description": "Aortic dysfunction/dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 1890.0, "minimum": 504.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 504.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1890.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1890.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81408", "type": "HCPCS" } ], "description": "Mopath procedure level 9", "standard_charges": [ { "billing_class": "facility", "maximum": 7500.0, "minimum": 2000.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2000.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83630", "type": "HCPCS" } ], "description": "Lactoferrin fecal (qual)", "standard_charges": [ { "billing_class": "facility", "maximum": 73.88, "minimum": 19.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83625", "type": "HCPCS" } ], "description": "Assay of ldh enzymes", "standard_charges": [ { "billing_class": "facility", "maximum": 47.96, "minimum": 12.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83615", "type": "HCPCS" } ], "description": "Lactate (LD) (LDH) enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 22.65, "minimum": 6.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83605", "type": "HCPCS" } ], "description": "Assay of lactic acid", "standard_charges": [ { "billing_class": "facility", "maximum": 43.39, "minimum": 11.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83593", "type": "HCPCS" } ], "description": "Fractionation ketosteroids", "standard_charges": [ { "billing_class": "facility", "maximum": 106.88, "minimum": 28.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 106.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83586", "type": "HCPCS" } ], "description": "Assay 17- ketosteroids", "standard_charges": [ { "billing_class": "facility", "maximum": 48.0, "minimum": 12.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83582", "type": "HCPCS" } ], "description": "Assay of ketogenic steroids", "standard_charges": [ { "billing_class": "facility", "maximum": 58.01, "minimum": 15.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83570", "type": "HCPCS" } ], "description": "Assay of idh enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 33.19, "minimum": 8.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83550", "type": "HCPCS" } ], "description": "Iron binding test", "standard_charges": [ { "billing_class": "facility", "maximum": 32.78, "minimum": 8.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83540", "type": "HCPCS" } ], "description": "Assay of iron", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83529", "type": "HCPCS" } ], "description": "Asay of interleukin-6 (il-6)", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83528", "type": "HCPCS" } ], "description": "Assay of intrinsic factor", "standard_charges": [ { "billing_class": "facility", "maximum": 74.33, "minimum": 19.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 74.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83527", "type": "HCPCS" } ], "description": "Assay of insulin", "standard_charges": [ { "billing_class": "facility", "maximum": 48.56, "minimum": 12.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83525", "type": "HCPCS" } ], "description": "Assay of insulin", "standard_charges": [ { "billing_class": "facility", "maximum": 42.86, "minimum": 11.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83521", "type": "HCPCS" } ], "description": "Ig light chains free each", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83520", "type": "HCPCS" } ], "description": "Immunoassay quant nos nonab", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83519", "type": "HCPCS" } ], "description": "Ria nonantibody", "standard_charges": [ { "billing_class": "facility", "maximum": 69.0, "minimum": 18.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83518", "type": "HCPCS" } ], "description": "Immunoassay dipstick", "standard_charges": [ { "billing_class": "facility", "maximum": 36.15, "minimum": 9.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83516", "type": "HCPCS" } ], "description": "Immunoassay nonantibody", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83505", "type": "HCPCS" } ], "description": "Assay total hydroxyproline", "standard_charges": [ { "billing_class": "facility", "maximum": 91.13, "minimum": 24.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 91.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 91.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83500", "type": "HCPCS" } ], "description": "Assay free hydroxyproline", "standard_charges": [ { "billing_class": "facility", "maximum": 84.94, "minimum": 22.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 84.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83498", "type": "HCPCS" } ], "description": "Assay of progesterone 17-d", "standard_charges": [ { "billing_class": "facility", "maximum": 101.89, "minimum": 27.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83497", "type": "HCPCS" } ], "description": "Assay of 5-hiaa", "standard_charges": [ { "billing_class": "facility", "maximum": 48.38, "minimum": 12.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83491", "type": "HCPCS" } ], "description": "Assay of corticosteroids 17", "standard_charges": [ { "billing_class": "facility", "maximum": 67.13, "minimum": 17.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83150", "type": "HCPCS" } ], "description": "Assay of homovanillic acid", "standard_charges": [ { "billing_class": "facility", "maximum": 84.04, "minimum": 22.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 84.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83090", "type": "HCPCS" } ], "description": "Assay Of Homocystine", "standard_charges": [ { "billing_class": "facility", "maximum": 67.2, "minimum": 17.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83088", "type": "HCPCS" } ], "description": "Assay of histamine", "standard_charges": [ { "billing_class": "facility", "maximum": 110.74, "minimum": 29.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 110.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9559", "type": "HCPCS" } ], "description": "Co57 cyano", "standard_charges": [ { "billing_class": "facility", "maximum": 682.87, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 682.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 682.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9560", "type": "HCPCS" } ], "description": "Tc99m labeled rbc", "standard_charges": [ { "billing_class": "facility", "maximum": 285.77, "minimum": 234.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 234.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 234.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 285.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 285.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9563", "type": "HCPCS" } ], "description": "P32 na phosphate", "standard_charges": [ { "billing_class": "facility", "maximum": 713.42, "minimum": 278.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 278.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 713.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 713.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 485.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 485.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9568", "type": "HCPCS" } ], "description": "Technetium tc99m arcitumomab", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.77, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9569", "type": "HCPCS" } ], "description": "Technetium TC-99m auto WBC", "standard_charges": [ { "billing_class": "facility", "maximum": 4010.69, "minimum": 934.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 934.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4010.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4010.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2819.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2819.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9570", "type": "HCPCS" } ], "description": "Indium In-111 auto WBC", "standard_charges": [ { "billing_class": "facility", "maximum": 9851.31, "minimum": 1103.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1103.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9851.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9851.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2795.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2795.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9571", "type": "HCPCS" } ], "description": "Indium IN-111 auto platelet", "standard_charges": [ { "billing_class": "facility", "maximum": 11578.88, "minimum": 9851.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9851.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9851.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11578.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11578.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9573", "type": "HCPCS" } ], "description": "Inj, gadopiclenol, 1 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 9.7, "minimum": 6.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.38 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9575", "type": "HCPCS" } ], "description": "Inj gadoterate meglumi 0.1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.33, "minimum": 0.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9576", "type": "HCPCS" } ], "description": "Inj prohance multipack", "standard_charges": [ { "billing_class": "facility", "maximum": 3.96, "minimum": 2.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9577", "type": "HCPCS" } ], "description": "Inj multihance", "standard_charges": [ { "billing_class": "facility", "maximum": 4.93, "minimum": 3.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9578", "type": "HCPCS" } ], "description": "Inj multihance multipack", "standard_charges": [ { "billing_class": "facility", "maximum": 4.85, "minimum": 3.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9579", "type": "HCPCS" } ], "description": "Gad-base MR contrast NOS,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 4.01, "minimum": 2.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.46 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9581", "type": "HCPCS" } ], "description": "Gadoxetate disodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 39.84, "minimum": 24.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 34.4 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 24.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9582", "type": "HCPCS" } ], "description": "Iodine I-123 iobenguane", "standard_charges": [ { "billing_class": "facility", "maximum": 11953.68, "minimum": 2317.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2317.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11953.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11953.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5622.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5622.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9583", "type": "HCPCS" } ], "description": "Gadofosveset trisodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9584", "type": "HCPCS" } ], "description": "Iodine i-123 ioflupane", "standard_charges": [ { "billing_class": "facility", "maximum": 5775.12, "minimum": 1387.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1387.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5775.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5775.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3761.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3761.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9585", "type": "HCPCS" } ], "description": "Gadobutrol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.76, "minimum": 0.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9586", "type": "HCPCS" } ], "description": "Florbetapir F18", "standard_charges": [ { "billing_class": "facility", "maximum": 6686.32, "minimum": 1825.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1825.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6686.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6686.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5947.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5947.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9587", "type": "HCPCS" } ], "description": "Gallium ga-68", "standard_charges": [ { "billing_class": "facility", "maximum": 138.45, "minimum": 49.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 49.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 130.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 130.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 138.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 138.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9588", "type": "HCPCS" } ], "description": "Fluciclovine f-18", "standard_charges": [ { "billing_class": "facility", "maximum": 1208.96, "minimum": 322.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 322.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1208.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1208.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 727.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 727.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9589", "type": "HCPCS" } ], "description": "Insti hexaminolevulinate hcl", "standard_charges": [ { "billing_class": "facility", "maximum": 3736.3, "minimum": 2343.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3226.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3226.18 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2343.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3736.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3736.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9590", "type": "HCPCS" } ], "description": "Iodine i-131 iobenguane 1mci", "standard_charges": [ { "billing_class": "facility", "maximum": 749.71, "minimum": 749.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 749.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 749.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9591", "type": "HCPCS" } ], "description": "Fluoroestradiol f 18", "standard_charges": [ { "billing_class": "facility", "maximum": 1799.86, "minimum": 460.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 460.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1799.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1799.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1351.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1351.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9592", "type": "HCPCS" } ], "description": "Copper cu 64 dotatate diag", "standard_charges": [ { "billing_class": "facility", "maximum": 2252.25, "minimum": 594.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 594.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2252.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2252.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1612.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1612.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9593", "type": "HCPCS" } ], "description": "Gallium ga-68 psma-11 ucsf", "standard_charges": [ { "billing_class": "facility", "maximum": 1820.19, "minimum": 550.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 550.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1820.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1820.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1449.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1449.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9594", "type": "HCPCS" } ], "description": "Gallium ga-68 psma-11, ucla", "standard_charges": [ { "billing_class": "facility", "maximum": 1782.17, "minimum": 363.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 363.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1782.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1782.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1008.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1008.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9595", "type": "HCPCS" } ], "description": "Piflu f-18, dia 1 millicurie", "standard_charges": [ { "billing_class": "facility", "maximum": 1357.9, "minimum": 346.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 346.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1357.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1357.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 900.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 900.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9596", "type": "HCPCS" } ], "description": "Gallium illuccix 1 millicure", "standard_charges": [ { "billing_class": "facility", "maximum": 2811.38, "minimum": 478.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 478.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2302.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2302.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2811.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2811.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9600", "type": "HCPCS" } ], "description": "Sr89 strontium", "standard_charges": [ { "billing_class": "facility", "maximum": 11236.58, "minimum": 4146.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4146.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8775.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8775.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11236.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11236.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9601", "type": "HCPCS" } ], "description": "Flortaucipir inj 1 millicuri", "standard_charges": [ { "billing_class": "facility", "maximum": 10054.1, "minimum": 819.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3710.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 819.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 819.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10054.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10054.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9602", "type": "HCPCS" } ], "description": "Fluorodopa f-18 diag per mci", "standard_charges": [ { "billing_class": "facility", "maximum": 1351.26, "minimum": 855.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 855.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1167.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1167.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1351.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1351.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83080", "type": "HCPCS" } ], "description": "Assay of b hexosaminidase", "standard_charges": [ { "billing_class": "facility", "maximum": 63.26, "minimum": 16.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83070", "type": "HCPCS" } ], "description": "Assay of hemosiderin qual", "standard_charges": [ { "billing_class": "facility", "maximum": 17.81, "minimum": 4.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83069", "type": "HCPCS" } ], "description": "Assay of urine hemoglobin", "standard_charges": [ { "billing_class": "facility", "maximum": 14.81, "minimum": 3.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83068", "type": "HCPCS" } ], "description": "Hemoglobin stability screen", "standard_charges": [ { "billing_class": "facility", "maximum": 35.51, "minimum": 9.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83065", "type": "HCPCS" } ], "description": "Assay of hemoglobin heat", "standard_charges": [ { "billing_class": "facility", "maximum": 33.75, "minimum": 9.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83060", "type": "HCPCS" } ], "description": "Blood sulfhemoglobin assay", "standard_charges": [ { "billing_class": "facility", "maximum": 33.0, "minimum": 8.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83051", "type": "HCPCS" } ], "description": "Assay of plasma hemoglobin", "standard_charges": [ { "billing_class": "facility", "maximum": 27.41, "minimum": 7.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83050", "type": "HCPCS" } ], "description": "Blood methemoglobin assay", "standard_charges": [ { "billing_class": "facility", "maximum": 30.75, "minimum": 8.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83045", "type": "HCPCS" } ], "description": "Blood methemoglobin test", "standard_charges": [ { "billing_class": "facility", "maximum": 24.34, "minimum": 6.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83037", "type": "HCPCS" } ], "description": "Glycosylated hb home device", "standard_charges": [ { "billing_class": "facility", "maximum": 36.41, "minimum": 9.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83036", "type": "HCPCS" } ], "description": "Glycosylated hemoglobin test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.41, "minimum": 9.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83033", "type": "HCPCS" } ], "description": "Fetal hemoglobin assay qual", "standard_charges": [ { "billing_class": "facility", "maximum": 30.0, "minimum": 8.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83030", "type": "HCPCS" } ], "description": "Fetal hemoglobin chemical", "standard_charges": [ { "billing_class": "facility", "maximum": 40.28, "minimum": 10.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83026", "type": "HCPCS" } ], "description": "Hemoglobin copper sulfate", "standard_charges": [ { "billing_class": "facility", "maximum": 15.04, "minimum": 4.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83021", "type": "HCPCS" } ], "description": "Hemoglobin chromotography", "standard_charges": [ { "billing_class": "facility", "maximum": 67.73, "minimum": 18.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83020", "type": "HCPCS" } ], "description": "Hemoglobin electrophoresis", "standard_charges": [ { "billing_class": "facility", "maximum": 48.26, "minimum": 12.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83018", "type": "HCPCS" } ], "description": "Heavy metal quant each nes", "standard_charges": [ { "billing_class": "facility", "maximum": 82.35, "minimum": 21.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83015", "type": "HCPCS" } ], "description": "Heavy metal qual any anal", "standard_charges": [ { "billing_class": "facility", "maximum": 78.53, "minimum": 20.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83014", "type": "HCPCS" } ], "description": "H pylori drug admin", "standard_charges": [ { "billing_class": "facility", "maximum": 29.48, "minimum": 7.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83013", "type": "HCPCS" } ], "description": "H pylori (c-13) breath", "standard_charges": [ { "billing_class": "facility", "maximum": 252.6, "minimum": 67.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 67.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 252.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 252.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83012", "type": "HCPCS" } ], "description": "Assay of haptoglobins", "standard_charges": [ { "billing_class": "facility", "maximum": 100.84, "minimum": 26.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83010", "type": "HCPCS" } ], "description": "Assay of haptoglobin quant", "standard_charges": [ { "billing_class": "facility", "maximum": 47.18, "minimum": 12.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83009", "type": "HCPCS" } ], "description": "H pylori (c-13) blood", "standard_charges": [ { "billing_class": "facility", "maximum": 252.6, "minimum": 67.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 67.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 252.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 252.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83006", "type": "HCPCS" } ], "description": "Growth stimulation gene 2", "standard_charges": [ { "billing_class": "facility", "maximum": 283.5, "minimum": 75.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 283.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 283.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83003", "type": "HCPCS" } ], "description": "Assay growth hormone (hgh)", "standard_charges": [ { "billing_class": "facility", "maximum": 62.51, "minimum": 16.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83002", "type": "HCPCS" } ], "description": "Assay of gonadotropin (lh)", "standard_charges": [ { "billing_class": "facility", "maximum": 69.45, "minimum": 18.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83001", "type": "HCPCS" } ], "description": "Assay of gonadotropin (fsh)", "standard_charges": [ { "billing_class": "facility", "maximum": 69.68, "minimum": 18.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82985", "type": "HCPCS" } ], "description": "Assay of glycated protein", "standard_charges": [ { "billing_class": "facility", "maximum": 62.85, "minimum": 16.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82979", "type": "HCPCS" } ], "description": "Assay rbc glutathione", "standard_charges": [ { "billing_class": "facility", "maximum": 35.4, "minimum": 9.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82978", "type": "HCPCS" } ], "description": "Assay of glutathione", "standard_charges": [ { "billing_class": "facility", "maximum": 57.94, "minimum": 15.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9603", "type": "HCPCS" } ], "description": "Inj, pafolacianine, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 310.78, "minimum": 310.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 310.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 310.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9604", "type": "HCPCS" } ], "description": "Sm 153 lexidronam", "standard_charges": [ { "billing_class": "facility", "maximum": 38101.94, "minimum": 3159.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3159.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38101.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 38101.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11693.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11693.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9606", "type": "HCPCS" } ], "description": "Radium ra223 dichloride ther", "standard_charges": [ { "billing_class": "facility", "maximum": 457.2, "minimum": 172.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 172.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 395.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 395.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 457.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 457.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9607", "type": "HCPCS" } ], "description": "Lutetium lu 177 vipivotide", "standard_charges": [ { "billing_class": "facility", "maximum": 653.68, "minimum": 255.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 255.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 556.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 556.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 653.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 653.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9608", "type": "HCPCS" } ], "description": "Flotufolastat f18 diag 1 mci", "standard_charges": [ { "billing_class": "facility", "maximum": 1766.03, "minimum": 671.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1481.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1481.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1766.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1766.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9610", "type": "HCPCS" } ], "description": "Xe129 xenon, diagnostic", "standard_charges": [ { "billing_class": "facility", "maximum": 2433.6, "minimum": 2433.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2433.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2433.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9800", "type": "HCPCS" } ], "description": "Gallium locametz 1 millicuri", "standard_charges": [ { "billing_class": "facility", "maximum": 2367.02, "minimum": 362.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 362.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1928.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1928.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2367.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2367.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9046", "type": "HCPCS" } ], "description": "Cocaine hcl nasal solution", "standard_charges": [ { "billing_class": "facility", "maximum": 3.58, "minimum": 3.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9047", "type": "HCPCS" } ], "description": "Injection, caplacizumab-yhdp", "standard_charges": [ { "billing_class": "facility", "maximum": 1753.29, "minimum": 802.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 802.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1753.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1753.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9067", "type": "HCPCS" } ], "description": "Gallium ga-68 dotatoc", "standard_charges": [ { "billing_class": "facility", "maximum": 17.74, "minimum": 3.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 17.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9088", "type": "HCPCS" } ], "description": "Instill, bupivac and meloxic", "standard_charges": [ { "billing_class": "facility", "maximum": 2.09, "minimum": 1.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9089", "type": "HCPCS" } ], "description": "Bupivacaine implant, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.94, "minimum": 1.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9101", "type": "HCPCS" } ], "description": "Inj, oliceridine 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.58, "minimum": 3.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9143", "type": "HCPCS" } ], "description": "Cocaine hcl nasal (numbrino)", "standard_charges": [ { "billing_class": "facility", "maximum": 5.24, "minimum": 5.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9144", "type": "HCPCS" } ], "description": "Inj, bupivacaine (posimir)", "standard_charges": [ { "billing_class": "facility", "maximum": 1.36, "minimum": 1.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9145", "type": "HCPCS" } ], "description": "Inj, aponvie, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.04, "minimum": 1.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9248", "type": "HCPCS" } ], "description": "Inj, clevidipine butyrate", "standard_charges": [ { "billing_class": "facility", "maximum": 8.0, "minimum": 7.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9254", "type": "HCPCS" } ], "description": "Injection, lacosamide", "standard_charges": [ { "billing_class": "facility", "maximum": 0.47, "minimum": 0.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9257", "type": "HCPCS" } ], "description": "Bevacizumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 4.96, "minimum": 1.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9285", "type": "HCPCS" } ], "description": "Patch, lidocaine/tetracaine", "standard_charges": [ { "billing_class": "facility", "maximum": 39.66, "minimum": 39.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 39.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9293", "type": "HCPCS" } ], "description": "Injection, glucarpidase", "standard_charges": [ { "billing_class": "facility", "maximum": 999.39, "minimum": 427.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 427.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 999.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 999.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9460", "type": "HCPCS" } ], "description": "Injection, cangrelor", "standard_charges": [ { "billing_class": "facility", "maximum": 51.0, "minimum": 19.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 44.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9462", "type": "HCPCS" } ], "description": "Injection, delafloxacin", "standard_charges": [ { "billing_class": "facility", "maximum": 1.1, "minimum": 1.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9482", "type": "HCPCS" } ], "description": "Sotalol hydrochloride IV", "standard_charges": [ { "billing_class": "facility", "maximum": 61.73, "minimum": 25.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 51.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9488", "type": "HCPCS" } ], "description": "Conivaptan HCL", "standard_charges": [ { "billing_class": "facility", "maximum": 104.29, "minimum": 104.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 104.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 104.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9898", "type": "HCPCS" } ], "description": "Inpnt stay radiolabeled item", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0121", "type": "HCPCS" } ], "description": "Inj., omadacycline, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 10.62, "minimum": 4.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0122", "type": "HCPCS" } ], "description": "Inj., eravacycline, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.28, "minimum": 1.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0129", "type": "HCPCS" } ], "description": "Abatacept injection", "standard_charges": [ { "billing_class": "facility", "maximum": 118.7, "minimum": 44.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 102.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 102.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 74.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 118.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 118.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0130", "type": "HCPCS" } ], "description": "Abciximab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1513.86, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1513.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1513.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0131", "type": "HCPCS" } ], "description": "Acetaminophen injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.14, "minimum": 0.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0132", "type": "HCPCS" } ], "description": "Acetylcysteine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.49, "minimum": 0.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82977", "type": "HCPCS" } ], "description": "Assay of GGT", "standard_charges": [ { "billing_class": "facility", "maximum": 27.0, "minimum": 7.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82965", "type": "HCPCS" } ], "description": "Assay of gdh enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 49.31, "minimum": 13.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82963", "type": "HCPCS" } ], "description": "Assay of glucosidase", "standard_charges": [ { "billing_class": "facility", "maximum": 80.55, "minimum": 21.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 80.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82962", "type": "HCPCS" } ], "description": "Glucose blood test", "standard_charges": [ { "billing_class": "facility", "maximum": 12.3, "minimum": 3.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82960", "type": "HCPCS" } ], "description": "Test for G6PD enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 22.69, "minimum": 6.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82955", "type": "HCPCS" } ], "description": "Assay of g6pd enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 36.38, "minimum": 9.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82952", "type": "HCPCS" } ], "description": "GTT-added samples", "standard_charges": [ { "billing_class": "facility", "maximum": 14.7, "minimum": 3.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82951", "type": "HCPCS" } ], "description": "Glucose tolerance test (GTT)", "standard_charges": [ { "billing_class": "facility", "maximum": 48.26, "minimum": 12.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82950", "type": "HCPCS" } ], "description": "Glucose test", "standard_charges": [ { "billing_class": "facility", "maximum": 17.81, "minimum": 4.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82948", "type": "HCPCS" } ], "description": "Reagent strip/blood glucose", "standard_charges": [ { "billing_class": "facility", "maximum": 18.9, "minimum": 5.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82947", "type": "HCPCS" } ], "description": "Assay glucose blood quant", "standard_charges": [ { "billing_class": "facility", "maximum": 14.74, "minimum": 3.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82946", "type": "HCPCS" } ], "description": "Glucagon tolerance test", "standard_charges": [ { "billing_class": "facility", "maximum": 66.64, "minimum": 17.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82945", "type": "HCPCS" } ], "description": "Glucose Other Fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 14.74, "minimum": 3.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82943", "type": "HCPCS" } ], "description": "Assay of glucagon", "standard_charges": [ { "billing_class": "facility", "maximum": 53.59, "minimum": 14.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82941", "type": "HCPCS" } ], "description": "Assay of gastrin", "standard_charges": [ { "billing_class": "facility", "maximum": 66.11, "minimum": 17.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82938", "type": "HCPCS" } ], "description": "Gastrin test", "standard_charges": [ { "billing_class": "facility", "maximum": 66.34, "minimum": 17.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82930", "type": "HCPCS" } ], "description": "Gastric analy w/ph ea spec", "standard_charges": [ { "billing_class": "facility", "maximum": 25.16, "minimum": 6.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82820", "type": "HCPCS" } ], "description": "Hemoglobin-oxygen affinity", "standard_charges": [ { "billing_class": "facility", "maximum": 50.03, "minimum": 13.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82810", "type": "HCPCS" } ], "description": "Blood gases o2 sat only", "standard_charges": [ { "billing_class": "facility", "maximum": 36.64, "minimum": 9.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82805", "type": "HCPCS" } ], "description": "Blood gases w/o2 saturation", "standard_charges": [ { "billing_class": "facility", "maximum": 295.39, "minimum": 78.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 295.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 295.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82803", "type": "HCPCS" } ], "description": "Blood gases any combination", "standard_charges": [ { "billing_class": "facility", "maximum": 97.76, "minimum": 26.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 97.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 97.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82800", "type": "HCPCS" } ], "description": "Blood pH", "standard_charges": [ { "billing_class": "facility", "maximum": 41.25, "minimum": 11.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82787", "type": "HCPCS" } ], "description": "Igg 1 2 3 or 4 each", "standard_charges": [ { "billing_class": "facility", "maximum": 30.08, "minimum": 8.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82785", "type": "HCPCS" } ], "description": "Assay of ige", "standard_charges": [ { "billing_class": "facility", "maximum": 61.73, "minimum": 16.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82784", "type": "HCPCS" } ], "description": "Assay iga/igd/igg/igm each", "standard_charges": [ { "billing_class": "facility", "maximum": 34.88, "minimum": 9.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82777", "type": "HCPCS" } ], "description": "Galectin-3", "standard_charges": [ { "billing_class": "facility", "maximum": 165.94, "minimum": 44.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 165.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 165.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82776", "type": "HCPCS" } ], "description": "Galactose transferase test", "standard_charges": [ { "billing_class": "facility", "maximum": 44.03, "minimum": 11.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82775", "type": "HCPCS" } ], "description": "Assay galactose transferase", "standard_charges": [ { "billing_class": "facility", "maximum": 79.01, "minimum": 21.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82760", "type": "HCPCS" } ], "description": "Assay of galactose", "standard_charges": [ { "billing_class": "facility", "maximum": 42.0, "minimum": 11.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82759", "type": "HCPCS" } ], "description": "Assay of rbc galactokinase", "standard_charges": [ { "billing_class": "facility", "maximum": 80.55, "minimum": 21.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 80.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0133", "type": "HCPCS" } ], "description": "Acyclovir injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.14, "minimum": 0.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0134", "type": "HCPCS" } ], "description": "Inj acetaminophen -fresenius", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0136", "type": "HCPCS" } ], "description": "Inj, acetaminophen (b braun)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.14, "minimum": 0.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0137", "type": "HCPCS" } ], "description": "Inj, acetaminophen (hikma)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.14, "minimum": 0.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0138", "type": "HCPCS" } ], "description": "Injection, acetaminoph 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.76, "minimum": 0.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0153", "type": "HCPCS" } ], "description": "Adenosine inj 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.75 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0171", "type": "HCPCS" } ], "description": "Adrenalin epinephrine inject", "standard_charges": [ { "billing_class": "facility", "maximum": 2.06, "minimum": 1.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.78 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0172", "type": "HCPCS" } ], "description": "Inj, aducanumab-avwa, 2 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 16.21, "minimum": 10.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 13.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0173", "type": "HCPCS" } ], "description": "Inj, epinephrine (belcher)", "standard_charges": [ { "billing_class": "facility", "maximum": 6.45, "minimum": 4.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0174", "type": "HCPCS" } ], "description": "Inj, lecanemab-irmb", "standard_charges": [ { "billing_class": "facility", "maximum": 3.6, "minimum": 1.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0175", "type": "HCPCS" } ], "description": "Inj, donanemab-azbt, 2 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 11.08, "minimum": 4.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0177", "type": "HCPCS" } ], "description": "Inj, aflibercept hd, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 891.75, "minimum": 311.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 311.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 770.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 770.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 559.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 891.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 891.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0178", "type": "HCPCS" } ], "description": "Aflibercept injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2170.9, "minimum": 771.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 771.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1874.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1874.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1361.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2170.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2170.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0179", "type": "HCPCS" } ], "description": "Inj, brolucizumab-dbll, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 918.39, "minimum": 346.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 346.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 793.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 793.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 576.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 918.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 918.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0180", "type": "HCPCS" } ], "description": "Agalsidase beta injection", "standard_charges": [ { "billing_class": "facility", "maximum": 605.74, "minimum": 230.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 523.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 523.04 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 379.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 605.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 605.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0184", "type": "HCPCS" } ], "description": "Inj, amisulpride, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 24.61, "minimum": 9.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0185", "type": "HCPCS" } ], "description": "Inj., aprepitant, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.61, "minimum": 1.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.98 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0202", "type": "HCPCS" } ], "description": "Injection, alemtuzumab", "standard_charges": [ { "billing_class": "facility", "maximum": 6540.21, "minimum": 2429.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2429.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5647.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5647.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4102.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6540.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6540.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0205", "type": "HCPCS" } ], "description": "Alglucerase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 81.52, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0206", "type": "HCPCS" } ], "description": "Inj allopurinol sodium 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 11.92, "minimum": 4.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0207", "type": "HCPCS" } ], "description": "Amifostine", "standard_charges": [ { "billing_class": "facility", "maximum": 2507.1, "minimum": 2206.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2507.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2507.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2206.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2206.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0208", "type": "HCPCS" } ], "description": "Inj sodium thiosulfate 100mg", "standard_charges": [ { "billing_class": "facility", "maximum": 260.16, "minimum": 95.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 95.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 213.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 213.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 260.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 260.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0210", "type": "HCPCS" } ], "description": "Methyldopate hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 135.5, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 135.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 135.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0215", "type": "HCPCS" } ], "description": "Alefacept", "standard_charges": [ { "billing_class": "facility", "maximum": 68.37, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0217", "type": "HCPCS" } ], "description": "Inj velmanase alfa-tycv 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1194.6, "minimum": 465.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 465.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1031.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1031.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 749.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1194.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1194.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0218", "type": "HCPCS" } ], "description": "Inj olipudase alfa-rpcp 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1034.08, "minimum": 393.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 393.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 892.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 892.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 648.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1034.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1034.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0219", "type": "HCPCS" } ], "description": "Inj aval alfa-nqpt 4mg", "standard_charges": [ { "billing_class": "facility", "maximum": 211.0, "minimum": 80.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 80.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 182.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 182.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 132.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 211.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 211.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0220", "type": "HCPCS" } ], "description": "Alglucosidase alfa injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0221", "type": "HCPCS" } ], "description": "Lumizyme injection", "standard_charges": [ { "billing_class": "facility", "maximum": 546.44, "minimum": 206.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 206.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 471.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 471.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 342.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 546.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 546.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0222", "type": "HCPCS" } ], "description": "Inj., patisiran, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 267.83, "minimum": 99.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 99.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 231.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 231.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 168.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 267.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 267.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0223", "type": "HCPCS" } ], "description": "Inj givosiran 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 312.92, "minimum": 117.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 117.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 270.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 270.2 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 196.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 312.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 312.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0224", "type": "HCPCS" } ], "description": "Inj. lumasiran, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 861.81, "minimum": 329.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 329.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 744.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 744.14 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 540.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 861.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 861.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82757", "type": "HCPCS" } ], "description": "Assay of semen fructose", "standard_charges": [ { "billing_class": "facility", "maximum": 65.03, "minimum": 17.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82747", "type": "HCPCS" } ], "description": "Assay of folic acid rbc", "standard_charges": [ { "billing_class": "facility", "maximum": 66.19, "minimum": 17.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82746", "type": "HCPCS" } ], "description": "Assay of folic acid serum", "standard_charges": [ { "billing_class": "facility", "maximum": 55.13, "minimum": 14.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82735", "type": "HCPCS" } ], "description": "Assay of fluoride", "standard_charges": [ { "billing_class": "facility", "maximum": 69.53, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82731", "type": "HCPCS" } ], "description": "Assay of fetal fibronectin", "standard_charges": [ { "billing_class": "facility", "maximum": 241.54, "minimum": 64.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82728", "type": "HCPCS" } ], "description": "Assay of ferritin", "standard_charges": [ { "billing_class": "facility", "maximum": 51.11, "minimum": 13.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82726", "type": "HCPCS" } ], "description": "Long chain fatty acids", "standard_charges": [ { "billing_class": "facility", "maximum": 74.06, "minimum": 19.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 74.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82725", "type": "HCPCS" } ], "description": "Assay of blood fatty acids", "standard_charges": [ { "billing_class": "facility", "maximum": 70.39, "minimum": 18.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82715", "type": "HCPCS" } ], "description": "Assay of fecal fat", "standard_charges": [ { "billing_class": "facility", "maximum": 86.14, "minimum": 22.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82710", "type": "HCPCS" } ], "description": "Fats/lipids feces quant", "standard_charges": [ { "billing_class": "facility", "maximum": 63.0, "minimum": 16.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82705", "type": "HCPCS" } ], "description": "Fats/lipids feces qual", "standard_charges": [ { "billing_class": "facility", "maximum": 19.13, "minimum": 5.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82696", "type": "HCPCS" } ], "description": "Assay of etiocholanolone", "standard_charges": [ { "billing_class": "facility", "maximum": 98.4, "minimum": 26.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 98.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 98.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82693", "type": "HCPCS" } ], "description": "Assay of ethylene glycol", "standard_charges": [ { "billing_class": "facility", "maximum": 55.88, "minimum": 14.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83631", "type": "HCPCS" } ], "description": "Lactoferrin fecal (quant)", "standard_charges": [ { "billing_class": "facility", "maximum": 73.61, "minimum": 19.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83632", "type": "HCPCS" } ], "description": "Placental lactogen", "standard_charges": [ { "billing_class": "facility", "maximum": 75.83, "minimum": 20.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83633", "type": "HCPCS" } ], "description": "Test urine for lactose", "standard_charges": [ { "billing_class": "facility", "maximum": 42.19, "minimum": 11.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83655", "type": "HCPCS" } ], "description": "Assay of lead", "standard_charges": [ { "billing_class": "facility", "maximum": 45.41, "minimum": 12.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83661", "type": "HCPCS" } ], "description": "L/s ratio fetal lung", "standard_charges": [ { "billing_class": "facility", "maximum": 82.46, "minimum": 21.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83662", "type": "HCPCS" } ], "description": "Foam stability fetal lung", "standard_charges": [ { "billing_class": "facility", "maximum": 70.91, "minimum": 18.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83663", "type": "HCPCS" } ], "description": "Fluoro polarize fetal lung", "standard_charges": [ { "billing_class": "facility", "maximum": 70.91, "minimum": 18.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83664", "type": "HCPCS" } ], "description": "Lamellar bdy fetal lung", "standard_charges": [ { "billing_class": "facility", "maximum": 72.45, "minimum": 19.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83670", "type": "HCPCS" } ], "description": "Assay of lap enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 36.79, "minimum": 9.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83690", "type": "HCPCS" } ], "description": "Assay of lipase", "standard_charges": [ { "billing_class": "facility", "maximum": 25.84, "minimum": 6.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83695", "type": "HCPCS" } ], "description": "Assay of lipoprotein(a)", "standard_charges": [ { "billing_class": "facility", "maximum": 53.7, "minimum": 14.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83698", "type": "HCPCS" } ], "description": "Assay Lipoprotein Pla2", "standard_charges": [ { "billing_class": "facility", "maximum": 173.66, "minimum": 46.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 173.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 173.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83700", "type": "HCPCS" } ], "description": "Lipopro bld electrophoretic", "standard_charges": [ { "billing_class": "facility", "maximum": 42.23, "minimum": 11.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83701", "type": "HCPCS" } ], "description": "Lipoprotein bld hr fraction", "standard_charges": [ { "billing_class": "facility", "maximum": 126.98, "minimum": 33.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 126.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 126.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83704", "type": "HCPCS" } ], "description": "Lipoprotein bld quan part", "standard_charges": [ { "billing_class": "facility", "maximum": 128.21, "minimum": 34.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 128.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 128.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83718", "type": "HCPCS" } ], "description": "Assay of lipoprotein", "standard_charges": [ { "billing_class": "facility", "maximum": 30.71, "minimum": 8.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83719", "type": "HCPCS" } ], "description": "Assay of blood lipoprotein", "standard_charges": [ { "billing_class": "facility", "maximum": 47.81, "minimum": 12.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0225", "type": "HCPCS" } ], "description": "Inj, vutrisiran, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 13327.1, "minimum": 5003.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5003.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11507.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11507.54 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8360.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13327.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13327.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0248", "type": "HCPCS" } ], "description": "Inj, remdesivir, 1 mg?", "standard_charges": [ { "billing_class": "facility", "maximum": 17.21, "minimum": 6.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 14.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0256", "type": "HCPCS" } ], "description": "Alpha 1 proteinase inhibitor", "standard_charges": [ { "billing_class": "facility", "maximum": 13.79, "minimum": 5.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0257", "type": "HCPCS" } ], "description": "Glassia injection", "standard_charges": [ { "billing_class": "facility", "maximum": 14.93, "minimum": 5.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0270", "type": "HCPCS" } ], "description": "Alprostadil for injection", "standard_charges": [ { "billing_class": "facility", "maximum": 24.03, "minimum": 1.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0278", "type": "HCPCS" } ], "description": "Amikacin sulfate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.46, "minimum": 0.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0280", "type": "HCPCS" } ], "description": "Aminophyllin 250 MG inj", "standard_charges": [ { "billing_class": "facility", "maximum": 14.01, "minimum": 8.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.1 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0282", "type": "HCPCS" } ], "description": "Amiodarone HCl", "standard_charges": [ { "billing_class": "facility", "maximum": 1.06, "minimum": 0.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0283", "type": "HCPCS" } ], "description": "Inj, amiodarone (nexterone)", "standard_charges": [ { "billing_class": "facility", "maximum": 6.83, "minimum": 4.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0285", "type": "HCPCS" } ], "description": "Amphotericin B", "standard_charges": [ { "billing_class": "facility", "maximum": 135.69, "minimum": 85.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 117.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 117.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 85.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 135.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 135.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0287", "type": "HCPCS" } ], "description": "Amphotericin b lipid complex", "standard_charges": [ { "billing_class": "facility", "maximum": 27.91, "minimum": 10.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0288", "type": "HCPCS" } ], "description": "Ampho b cholesteryl sulfate", "standard_charges": [ { "billing_class": "facility", "maximum": 191.98, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 191.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 191.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0289", "type": "HCPCS" } ], "description": "Amphotericin b liposome inj", "standard_charges": [ { "billing_class": "facility", "maximum": 64.99, "minimum": 21.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 56.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 56.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 40.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0290", "type": "HCPCS" } ], "description": "Ampicillin 500 MG inj", "standard_charges": [ { "billing_class": "facility", "maximum": 1.92, "minimum": 1.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0291", "type": "HCPCS" } ], "description": "Inj., plazomicin, 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 9.67, "minimum": 3.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.35 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0295", "type": "HCPCS" } ], "description": "Ampicillin sodium per 1.5 gm", "standard_charges": [ { "billing_class": "facility", "maximum": 4.44, "minimum": 2.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0300", "type": "HCPCS" } ], "description": "Amobarbital 125 MG inj", "standard_charges": [ { "billing_class": "facility", "maximum": 428.83, "minimum": 30.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 428.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 428.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0330", "type": "HCPCS" } ], "description": "Succinycholine chloride inj", "standard_charges": [ { "billing_class": "facility", "maximum": 4.28, "minimum": 1.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0348", "type": "HCPCS" } ], "description": "Anidulafungin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.38, "minimum": 0.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0349", "type": "HCPCS" } ], "description": "Inj, rezafungin, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 28.24, "minimum": 10.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.38 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0360", "type": "HCPCS" } ], "description": "Hydralazine hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 11.06, "minimum": 6.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.55 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0364", "type": "HCPCS" } ], "description": "Apomorphine hydrochloride", "standard_charges": [ { "billing_class": "facility", "maximum": 143.71, "minimum": 81.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 81.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 81.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 143.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 143.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0365", "type": "HCPCS" } ], "description": "Aprotonin, 10,000 kiu", "standard_charges": [ { "billing_class": "facility", "maximum": 7.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0391", "type": "HCPCS" } ], "description": "Inj, artesunate, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 140.46, "minimum": 51.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 105.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 105.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 140.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0400", "type": "HCPCS" } ], "description": "Aripiprazole injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0401", "type": "HCPCS" } ], "description": "Inj aripiprazole ext rel 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 19.16, "minimum": 7.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 16.54 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0402", "type": "HCPCS" } ], "description": "Inj, abilify asimtufii, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 16.04, "minimum": 6.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 13.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0456", "type": "HCPCS" } ], "description": "Azithromycin", "standard_charges": [ { "billing_class": "facility", "maximum": 5.77, "minimum": 3.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.98 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0457", "type": "HCPCS" } ], "description": "Injection, aztreonam, 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.61, "minimum": 3.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0461", "type": "HCPCS" } ], "description": "Atropine sulfate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.3, "minimum": 0.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0470", "type": "HCPCS" } ], "description": "Dimecaprol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 173.93, "minimum": 132.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 132.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 132.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 173.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 173.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0475", "type": "HCPCS" } ], "description": "Baclofen 10 mg injection", "standard_charges": [ { "billing_class": "facility", "maximum": 471.11, "minimum": 181.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 181.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 406.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 406.79 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 295.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 471.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 471.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83721", "type": "HCPCS" } ], "description": "Assay of blood lipoprotein", "standard_charges": [ { "billing_class": "facility", "maximum": 39.38, "minimum": 10.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83722", "type": "HCPCS" } ], "description": "Lipoprtn dir meas sd ldl chl", "standard_charges": [ { "billing_class": "facility", "maximum": 128.21, "minimum": 34.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 128.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 128.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83727", "type": "HCPCS" } ], "description": "Assay of lrh hormone", "standard_charges": [ { "billing_class": "facility", "maximum": 64.46, "minimum": 17.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83735", "type": "HCPCS" } ], "description": "Assay of magnesium", "standard_charges": [ { "billing_class": "facility", "maximum": 25.13, "minimum": 6.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83775", "type": "HCPCS" } ], "description": "Assay malate dehydrogenase", "standard_charges": [ { "billing_class": "facility", "maximum": 27.64, "minimum": 7.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83785", "type": "HCPCS" } ], "description": "Assay of manganese", "standard_charges": [ { "billing_class": "facility", "maximum": 99.94, "minimum": 26.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83789", "type": "HCPCS" } ], "description": "Mass spectrometry qual/quan", "standard_charges": [ { "billing_class": "facility", "maximum": 90.41, "minimum": 24.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83825", "type": "HCPCS" } ], "description": "Assay of mercury", "standard_charges": [ { "billing_class": "facility", "maximum": 60.98, "minimum": 16.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83835", "type": "HCPCS" } ], "description": "Assay of metanephrines", "standard_charges": [ { "billing_class": "facility", "maximum": 63.53, "minimum": 16.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83857", "type": "HCPCS" } ], "description": "Assay of methemalbumin", "standard_charges": [ { "billing_class": "facility", "maximum": 40.28, "minimum": 10.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83861", "type": "HCPCS" } ], "description": "Microfluid analy tears", "standard_charges": [ { "billing_class": "facility", "maximum": 84.3, "minimum": 22.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 84.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83864", "type": "HCPCS" } ], "description": "Mucopolysaccharides", "standard_charges": [ { "billing_class": "facility", "maximum": 106.88, "minimum": 28.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 106.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83872", "type": "HCPCS" } ], "description": "Assay synovial fluid mucin", "standard_charges": [ { "billing_class": "facility", "maximum": 21.98, "minimum": 5.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83873", "type": "HCPCS" } ], "description": "Assay of csf protein", "standard_charges": [ { "billing_class": "facility", "maximum": 64.5, "minimum": 17.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83874", "type": "HCPCS" } ], "description": "Assay of myoglobin", "standard_charges": [ { "billing_class": "facility", "maximum": 48.45, "minimum": 12.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83876", "type": "HCPCS" } ], "description": "Assay myeloperoxidase", "standard_charges": [ { "billing_class": "facility", "maximum": 190.73, "minimum": 50.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 190.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 190.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83880", "type": "HCPCS" } ], "description": "Assay of natriuretic peptide", "standard_charges": [ { "billing_class": "facility", "maximum": 147.23, "minimum": 39.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 147.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83883", "type": "HCPCS" } ], "description": "Assay nephelometry not spec", "standard_charges": [ { "billing_class": "facility", "maximum": 51.0, "minimum": 13.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83885", "type": "HCPCS" } ], "description": "Assay of nickel", "standard_charges": [ { "billing_class": "facility", "maximum": 91.91, "minimum": 24.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 91.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 91.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83915", "type": "HCPCS" } ], "description": "Assay of nucleotidase", "standard_charges": [ { "billing_class": "facility", "maximum": 41.81, "minimum": 11.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83916", "type": "HCPCS" } ], "description": "Oligoclonal bands", "standard_charges": [ { "billing_class": "facility", "maximum": 102.71, "minimum": 27.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83918", "type": "HCPCS" } ], "description": "Organic acids total quant", "standard_charges": [ { "billing_class": "facility", "maximum": 88.5, "minimum": 23.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 88.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83919", "type": "HCPCS" } ], "description": "Organic acids qual each", "standard_charges": [ { "billing_class": "facility", "maximum": 61.69, "minimum": 16.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83921", "type": "HCPCS" } ], "description": "Organic acid single quant", "standard_charges": [ { "billing_class": "facility", "maximum": 79.54, "minimum": 21.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83930", "type": "HCPCS" } ], "description": "Assay of blood osmolality", "standard_charges": [ { "billing_class": "facility", "maximum": 24.79, "minimum": 6.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83935", "type": "HCPCS" } ], "description": "Assay of urine osmolality", "standard_charges": [ { "billing_class": "facility", "maximum": 25.58, "minimum": 6.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83937", "type": "HCPCS" } ], "description": "Assay of osteocalcin", "standard_charges": [ { "billing_class": "facility", "maximum": 111.94, "minimum": 29.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83945", "type": "HCPCS" } ], "description": "Assay of oxalate", "standard_charges": [ { "billing_class": "facility", "maximum": 54.19, "minimum": 14.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83950", "type": "HCPCS" } ], "description": "Oncoprotein her-2/neu", "standard_charges": [ { "billing_class": "facility", "maximum": 241.54, "minimum": 64.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83951", "type": "HCPCS" } ], "description": "Oncoprotein dcp", "standard_charges": [ { "billing_class": "facility", "maximum": 241.54, "minimum": 64.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83970", "type": "HCPCS" } ], "description": "Assay of parathormone", "standard_charges": [ { "billing_class": "facility", "maximum": 154.8, "minimum": 41.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 154.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 154.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83986", "type": "HCPCS" } ], "description": "Assay ph body fluid nos", "standard_charges": [ { "billing_class": "facility", "maximum": 13.43, "minimum": 3.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83987", "type": "HCPCS" } ], "description": "Exhaled breath condensate", "standard_charges": [ { "billing_class": "facility", "maximum": 13.43, "minimum": 3.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83992", "type": "HCPCS" } ], "description": "Assay for phencyclidine", "standard_charges": [ { "billing_class": "facility", "maximum": 138.53, "minimum": 138.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 138.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 138.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83993", "type": "HCPCS" } ], "description": "Assay for calprotectin fecal", "standard_charges": [ { "billing_class": "facility", "maximum": 73.61, "minimum": 19.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84030", "type": "HCPCS" } ], "description": "Assay of blood pku", "standard_charges": [ { "billing_class": "facility", "maximum": 20.63, "minimum": 5.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84035", "type": "HCPCS" } ], "description": "Assay of phenylketones", "standard_charges": [ { "billing_class": "facility", "maximum": 14.93, "minimum": 3.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84060", "type": "HCPCS" } ], "description": "Assay acid phosphatase", "standard_charges": [ { "billing_class": "facility", "maximum": 28.65, "minimum": 7.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84066", "type": "HCPCS" } ], "description": "Assay prostate phosphatase", "standard_charges": [ { "billing_class": "facility", "maximum": 36.23, "minimum": 9.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84075", "type": "HCPCS" } ], "description": "Assay alkaline phosphatase", "standard_charges": [ { "billing_class": "facility", "maximum": 19.43, "minimum": 5.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84078", "type": "HCPCS" } ], "description": "Assay alkaline phosphatase", "standard_charges": [ { "billing_class": "facility", "maximum": 30.98, "minimum": 8.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84080", "type": "HCPCS" } ], "description": "Assay alkaline phosphatases", "standard_charges": [ { "billing_class": "facility", "maximum": 55.43, "minimum": 14.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84081", "type": "HCPCS" } ], "description": "Assay phosphatidylglycerol", "standard_charges": [ { "billing_class": "facility", "maximum": 61.95, "minimum": 16.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84085", "type": "HCPCS" } ], "description": "Assay of rbc pg6d enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 35.4, "minimum": 9.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84087", "type": "HCPCS" } ], "description": "Assay phosphohexose enzymes", "standard_charges": [ { "billing_class": "facility", "maximum": 40.24, "minimum": 10.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84100", "type": "HCPCS" } ], "description": "Assay of phosphorus", "standard_charges": [ { "billing_class": "facility", "maximum": 17.78, "minimum": 4.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84105", "type": "HCPCS" } ], "description": "Assay of urine phosphorus", "standard_charges": [ { "billing_class": "facility", "maximum": 21.68, "minimum": 5.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84106", "type": "HCPCS" } ], "description": "Test for porphobilinogen", "standard_charges": [ { "billing_class": "facility", "maximum": 21.83, "minimum": 5.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84110", "type": "HCPCS" } ], "description": "Assay of porphobilinogen", "standard_charges": [ { "billing_class": "facility", "maximum": 31.65, "minimum": 8.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84112", "type": "HCPCS" } ], "description": "Eval amniotic fluid protein", "standard_charges": [ { "billing_class": "facility", "maximum": 367.91, "minimum": 98.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 98.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 367.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 367.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84119", "type": "HCPCS" } ], "description": "Test urine for porphyrins", "standard_charges": [ { "billing_class": "facility", "maximum": 50.1, "minimum": 13.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84120", "type": "HCPCS" } ], "description": "Assay of urine porphyrins", "standard_charges": [ { "billing_class": "facility", "maximum": 55.16, "minimum": 14.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84126", "type": "HCPCS" } ], "description": "Assay of feces porphyrins", "standard_charges": [ { "billing_class": "facility", "maximum": 146.66, "minimum": 39.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 146.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 146.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84132", "type": "HCPCS" } ], "description": "Assay of serum potassium", "standard_charges": [ { "billing_class": "facility", "maximum": 17.85, "minimum": 4.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84133", "type": "HCPCS" } ], "description": "Assay of urine potassium", "standard_charges": [ { "billing_class": "facility", "maximum": 17.74, "minimum": 4.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84134", "type": "HCPCS" } ], "description": "Assay of prealbumin", "standard_charges": [ { "billing_class": "facility", "maximum": 54.71, "minimum": 14.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84135", "type": "HCPCS" } ], "description": "Assay of pregnanediol", "standard_charges": [ { "billing_class": "facility", "maximum": 79.76, "minimum": 21.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84138", "type": "HCPCS" } ], "description": "Assay of pregnanetriol", "standard_charges": [ { "billing_class": "facility", "maximum": 78.94, "minimum": 21.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84140", "type": "HCPCS" } ], "description": "Assay of pregnenolone", "standard_charges": [ { "billing_class": "facility", "maximum": 77.51, "minimum": 20.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84143", "type": "HCPCS" } ], "description": "Assay of 17-hydroxypregneno", "standard_charges": [ { "billing_class": "facility", "maximum": 85.54, "minimum": 22.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 85.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0476", "type": "HCPCS" } ], "description": "Baclofen intrathecal trial", "standard_charges": [ { "billing_class": "facility", "maximum": 110.38, "minimum": 69.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 95.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 95.31 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 69.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 110.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0480", "type": "HCPCS" } ], "description": "Basiliximab", "standard_charges": [ { "billing_class": "facility", "maximum": 12622.04, "minimum": 4686.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4686.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10898.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10898.74 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7917.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12622.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12622.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0485", "type": "HCPCS" } ], "description": "Belatacept injection", "standard_charges": [ { "billing_class": "facility", "maximum": 10.65, "minimum": 3.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.2 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0490", "type": "HCPCS" } ], "description": "Belimumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 148.81, "minimum": 56.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 128.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 128.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 93.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 148.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 148.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0491", "type": "HCPCS" } ], "description": "Inj anifrolumab-fnia 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 48.13, "minimum": 18.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 41.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 30.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0500", "type": "HCPCS" } ], "description": "Dicyclomine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 40.38, "minimum": 25.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 34.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 25.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0515", "type": "HCPCS" } ], "description": "Inj benztropine mesylate", "standard_charges": [ { "billing_class": "facility", "maximum": 45.77, "minimum": 28.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 39.52 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 28.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0517", "type": "HCPCS" } ], "description": "Inj., benralizumab, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 449.56, "minimum": 164.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 388.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 388.18 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 282.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 449.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 449.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0558", "type": "HCPCS" } ], "description": "PenG benzathine/procaine inj", "standard_charges": [ { "billing_class": "facility", "maximum": 47.07, "minimum": 19.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 40.65 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 29.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0561", "type": "HCPCS" } ], "description": "Penicillin g benzathine inj", "standard_charges": [ { "billing_class": "facility", "maximum": 72.68, "minimum": 30.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 62.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 62.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 45.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0565", "type": "HCPCS" } ], "description": "Inj, bezlotoxumab, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 108.05, "minimum": 39.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 93.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 93.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 67.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 108.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 108.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0567", "type": "HCPCS" } ], "description": "Inj., cerliponase alfa 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 356.91, "minimum": 120.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 120.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 259.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 259.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 356.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 356.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0571", "type": "HCPCS" } ], "description": "Buprenorphine oral 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.79, "minimum": 1.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0577", "type": "HCPCS" } ], "description": "Inj, brixadi, 7 days or less", "standard_charges": [ { "billing_class": "facility", "maximum": 1161.67, "minimum": 420.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 420.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1003.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1003.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 728.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1161.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1161.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0578", "type": "HCPCS" } ], "description": "Inj brixadi, more than 7 day", "standard_charges": [ { "billing_class": "facility", "maximum": 4646.65, "minimum": 1682.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1682.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4012.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4012.23 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2914.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4646.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4646.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0583", "type": "HCPCS" } ], "description": "Bivalirudin", "standard_charges": [ { "billing_class": "facility", "maximum": 0.43, "minimum": 0.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0584", "type": "HCPCS" } ], "description": "Injection, burosumab-twza 1m", "standard_charges": [ { "billing_class": "facility", "maximum": 1272.97, "minimum": 484.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 484.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1099.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1099.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 798.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1272.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1272.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0585", "type": "HCPCS" } ], "description": "Injection,onabotulinumtoxina", "standard_charges": [ { "billing_class": "facility", "maximum": 17.53, "minimum": 6.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.14 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0586", "type": "HCPCS" } ], "description": "Abobotulinumtoxina", "standard_charges": [ { "billing_class": "facility", "maximum": 23.12, "minimum": 8.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.96 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0587", "type": "HCPCS" } ], "description": "Inj, rimabotulinumtoxinb", "standard_charges": [ { "billing_class": "facility", "maximum": 35.2, "minimum": 13.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 30.4 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 22.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0588", "type": "HCPCS" } ], "description": "Incobotulinumtoxin a", "standard_charges": [ { "billing_class": "facility", "maximum": 14.39, "minimum": 5.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0589", "type": "HCPCS" } ], "description": "Inj daxibotulinumtoxina-lanm", "standard_charges": [ { "billing_class": "facility", "maximum": 9.83, "minimum": 3.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0591", "type": "HCPCS" } ], "description": "Inj deoxycholic acid, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 35.1, "minimum": 35.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 35.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0592", "type": "HCPCS" } ], "description": "Buprenorphine hydrochloride", "standard_charges": [ { "billing_class": "facility", "maximum": 11.65, "minimum": 7.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0593", "type": "HCPCS" } ], "description": "Inj., lanadelumab-flyo, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 278.72, "minimum": 87.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 87.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 199.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 199.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 278.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 278.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0594", "type": "HCPCS" } ], "description": "Busulfan injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.85, "minimum": 0.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0595", "type": "HCPCS" } ], "description": "Butorphanol tartrate 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 15.39, "minimum": 9.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 13.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0596", "type": "HCPCS" } ], "description": "Injection, ruconest", "standard_charges": [ { "billing_class": "facility", "maximum": 93.96, "minimum": 36.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 81.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 81.13 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 58.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0597", "type": "HCPCS" } ], "description": "C-1 esterase, berinert", "standard_charges": [ { "billing_class": "facility", "maximum": 196.37, "minimum": 75.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 169.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 169.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 123.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 196.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 196.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0598", "type": "HCPCS" } ], "description": "C-1 esterase, cinryze", "standard_charges": [ { "billing_class": "facility", "maximum": 173.63, "minimum": 65.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 65.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 149.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 149.92 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 108.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 173.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 173.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0599", "type": "HCPCS" } ], "description": "Inj., haegarda 10 units", "standard_charges": [ { "billing_class": "facility", "maximum": 39.16, "minimum": 27.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 27.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0600", "type": "HCPCS" } ], "description": "Edetate calcium disodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 16487.91, "minimum": 6408.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6408.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14236.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 14236.79 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10342.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16487.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16487.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0604", "type": "HCPCS" } ], "description": "Cinacalcet, esrd on dialysis", "standard_charges": [ { "billing_class": "facility", "maximum": 2.68, "minimum": 0.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0606", "type": "HCPCS" } ], "description": "Inj, etelcalcetide, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 12.79, "minimum": 2.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0612", "type": "HCPCS" } ], "description": "Calcium glucon (fresenius)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0613", "type": "HCPCS" } ], "description": "Calcium glucon (wg critical)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.3, "minimum": 0.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0620", "type": "HCPCS" } ], "description": "Calcium glycer & lact/10 ML", "standard_charges": [ { "billing_class": "facility", "maximum": 29.81, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0630", "type": "HCPCS" } ], "description": "Calcitonin salmon injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3095.93, "minimum": 1942.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2673.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2673.24 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1942.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3095.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3095.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0636", "type": "HCPCS" } ], "description": "Inj calcitriol per 0.1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.9, "minimum": 2.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0637", "type": "HCPCS" } ], "description": "Caspofungin acetate", "standard_charges": [ { "billing_class": "facility", "maximum": 13.71, "minimum": 8.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0638", "type": "HCPCS" } ], "description": "Canakinumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 368.23, "minimum": 141.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 141.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 317.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 317.96 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 230.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 368.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 368.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0640", "type": "HCPCS" } ], "description": "Leucovorin calcium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 11.27, "minimum": 7.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0641", "type": "HCPCS" } ], "description": "Levoleucovorin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0642", "type": "HCPCS" } ], "description": "Injection, khapzory, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.66, "minimum": 2.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0650", "type": "HCPCS" } ], "description": "Inj, levothyroxine nos 10mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 14.61, "minimum": 9.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0651", "type": "HCPCS" } ], "description": "Inj, levothyroxine, freskabi", "standard_charges": [ { "billing_class": "facility", "maximum": 10.35, "minimum": 6.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.94 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0652", "type": "HCPCS" } ], "description": "Inj, levothyroxine, hikma", "standard_charges": [ { "billing_class": "facility", "maximum": 13.93, "minimum": 8.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0665", "type": "HCPCS" } ], "description": "Inj, bupivacaine, nos, 0.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0670", "type": "HCPCS" } ], "description": "Inj mepivacaine HCL/10 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 9.62, "minimum": 6.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.31 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0687", "type": "HCPCS" } ], "description": "Inj cefazolin (wg crit care)", "standard_charges": [ { "billing_class": "facility", "maximum": 3.01, "minimum": 1.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0688", "type": "HCPCS" } ], "description": "Inj cefazolin sodium, hikma", "standard_charges": [ { "billing_class": "facility", "maximum": 2.71, "minimum": 1.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.34 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0689", "type": "HCPCS" } ], "description": "Inj cefazolin sodium, baxter", "standard_charges": [ { "billing_class": "facility", "maximum": 3.33, "minimum": 2.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.88 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0690", "type": "HCPCS" } ], "description": "Cefazolin sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2.2, "minimum": 1.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0691", "type": "HCPCS" } ], "description": "Inj lefamulin 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.22, "minimum": 1.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0692", "type": "HCPCS" } ], "description": "Cefepime hcl for injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.36, "minimum": 2.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0694", "type": "HCPCS" } ], "description": "Cefoxitin sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 12.06, "minimum": 7.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0695", "type": "HCPCS" } ], "description": "Inj ceftolozane tazobactam", "standard_charges": [ { "billing_class": "facility", "maximum": 22.09, "minimum": 9.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 13.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0696", "type": "HCPCS" } ], "description": "Ceftriaxone sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.22, "minimum": 0.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.05 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0697", "type": "HCPCS" } ], "description": "Sterile cefuroxime injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5.12, "minimum": 3.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0698", "type": "HCPCS" } ], "description": "Cefotaxime sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 22.93, "minimum": 16.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0699", "type": "HCPCS" } ], "description": "Inj, cefiderocol, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 6.18, "minimum": 2.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.34 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0701", "type": "HCPCS" } ], "description": "Inj. cefepime hcl (baxter)", "standard_charges": [ { "billing_class": "facility", "maximum": 15.56, "minimum": 9.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 13.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0702", "type": "HCPCS" } ], "description": "Betamethasone acet&sod phosp", "standard_charges": [ { "billing_class": "facility", "maximum": 20.35, "minimum": 12.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 17.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0703", "type": "HCPCS" } ], "description": "Inj, cefepime hcl (b braun)", "standard_charges": [ { "billing_class": "facility", "maximum": 13.33, "minimum": 8.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.51 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84144", "type": "HCPCS" } ], "description": "Assay of progesterone", "standard_charges": [ { "billing_class": "facility", "maximum": 78.23, "minimum": 20.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84145", "type": "HCPCS" } ], "description": "Procalcitonin (PCT)", "standard_charges": [ { "billing_class": "facility", "maximum": 102.08, "minimum": 27.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84146", "type": "HCPCS" } ], "description": "Assay of prolactin", "standard_charges": [ { "billing_class": "facility", "maximum": 72.68, "minimum": 19.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84150", "type": "HCPCS" } ], "description": "Assay of prostaglandin", "standard_charges": [ { "billing_class": "facility", "maximum": 156.64, "minimum": 41.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84152", "type": "HCPCS" } ], "description": "Assay of psa complexed", "standard_charges": [ { "billing_class": "facility", "maximum": 68.96, "minimum": 18.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84153", "type": "HCPCS" } ], "description": "Assay of psa total", "standard_charges": [ { "billing_class": "facility", "maximum": 68.96, "minimum": 18.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84154", "type": "HCPCS" } ], "description": "Assay of psa free", "standard_charges": [ { "billing_class": "facility", "maximum": 68.96, "minimum": 18.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84155", "type": "HCPCS" } ], "description": "Assay of protein serum", "standard_charges": [ { "billing_class": "facility", "maximum": 13.76, "minimum": 3.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84156", "type": "HCPCS" } ], "description": "Assay of protein urine", "standard_charges": [ { "billing_class": "facility", "maximum": 13.76, "minimum": 3.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84157", "type": "HCPCS" } ], "description": "Assay of protein other", "standard_charges": [ { "billing_class": "facility", "maximum": 15.0, "minimum": 4.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84160", "type": "HCPCS" } ], "description": "Assay of protein any source", "standard_charges": [ { "billing_class": "facility", "maximum": 21.04, "minimum": 5.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84163", "type": "HCPCS" } ], "description": "Pappa serum", "standard_charges": [ { "billing_class": "facility", "maximum": 56.44, "minimum": 15.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84165", "type": "HCPCS" } ], "description": "Protein e-phoresis serum", "standard_charges": [ { "billing_class": "facility", "maximum": 40.28, "minimum": 10.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84166", "type": "HCPCS" } ], "description": "Protein e-phoresis/urine/csf", "standard_charges": [ { "billing_class": "facility", "maximum": 66.86, "minimum": 17.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84181", "type": "HCPCS" } ], "description": "Western blot test", "standard_charges": [ { "billing_class": "facility", "maximum": 63.86, "minimum": 17.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84270", "type": "HCPCS" } ], "description": "Assay of sex hormone globul", "standard_charges": [ { "billing_class": "facility", "maximum": 81.49, "minimum": 21.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84275", "type": "HCPCS" } ], "description": "Assay of sialic acid", "standard_charges": [ { "billing_class": "facility", "maximum": 50.4, "minimum": 13.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84285", "type": "HCPCS" } ], "description": "Assay of silica", "standard_charges": [ { "billing_class": "facility", "maximum": 94.54, "minimum": 25.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84295", "type": "HCPCS" } ], "description": "Assay of serum sodium", "standard_charges": [ { "billing_class": "facility", "maximum": 18.04, "minimum": 4.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84300", "type": "HCPCS" } ], "description": "Assay of urine sodium", "standard_charges": [ { "billing_class": "facility", "maximum": 18.98, "minimum": 5.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84302", "type": "HCPCS" } ], "description": "Assay of sweat sodium", "standard_charges": [ { "billing_class": "facility", "maximum": 18.23, "minimum": 4.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84305", "type": "HCPCS" } ], "description": "Assay of somatomedin", "standard_charges": [ { "billing_class": "facility", "maximum": 79.73, "minimum": 21.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84307", "type": "HCPCS" } ], "description": "Assay of somatostatin", "standard_charges": [ { "billing_class": "facility", "maximum": 68.55, "minimum": 18.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84311", "type": "HCPCS" } ], "description": "Spectrophotometry", "standard_charges": [ { "billing_class": "facility", "maximum": 30.38, "minimum": 8.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84315", "type": "HCPCS" } ], "description": "Body fluid specific gravity", "standard_charges": [ { "billing_class": "facility", "maximum": 12.3, "minimum": 3.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84375", "type": "HCPCS" } ], "description": "Chromatogram assay sugars", "standard_charges": [ { "billing_class": "facility", "maximum": 146.25, "minimum": 39.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 146.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 146.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84376", "type": "HCPCS" } ], "description": "Sugars single qual", "standard_charges": [ { "billing_class": "facility", "maximum": 20.63, "minimum": 5.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84377", "type": "HCPCS" } ], "description": "Sugars multiple qual", "standard_charges": [ { "billing_class": "facility", "maximum": 20.63, "minimum": 5.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84378", "type": "HCPCS" } ], "description": "Sugars single quant", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84379", "type": "HCPCS" } ], "description": "Sugars multiple quant", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0706", "type": "HCPCS" } ], "description": "Caffeine citrate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5.45, "minimum": 3.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0712", "type": "HCPCS" } ], "description": "Ceftaroline fosamil inj", "standard_charges": [ { "billing_class": "facility", "maximum": 10.7, "minimum": 4.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.24 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0713", "type": "HCPCS" } ], "description": "Inj ceftazidime per 500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.47, "minimum": 2.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0714", "type": "HCPCS" } ], "description": "Ceftazidime and avibactam", "standard_charges": [ { "billing_class": "facility", "maximum": 272.98, "minimum": 104.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 104.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 235.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 235.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 171.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 272.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 272.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0715", "type": "HCPCS" } ], "description": "Ceftizoxime sodium / 500 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0716", "type": "HCPCS" } ], "description": "Centruroides immune f(ab)", "standard_charges": [ { "billing_class": "facility", "maximum": 13005.56, "minimum": 4871.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4871.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12275.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12275.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13005.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13005.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0717", "type": "HCPCS" } ], "description": "Certolizumab pegol inj 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 10.57, "minimum": 3.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.13 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0720", "type": "HCPCS" } ], "description": "Chloramphenicol sodium injec", "standard_charges": [ { "billing_class": "facility", "maximum": 158.21, "minimum": 50.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 113.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 113.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 158.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 158.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0725", "type": "HCPCS" } ], "description": "Chorionic gonadotropin/1000u", "standard_charges": [ { "billing_class": "facility", "maximum": 53.31, "minimum": 33.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 46.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 33.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0735", "type": "HCPCS" } ], "description": "Clonidine hydrochloride", "standard_charges": [ { "billing_class": "facility", "maximum": 45.37, "minimum": 28.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 39.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 28.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0736", "type": "HCPCS" } ], "description": "Inj, clindamycin phosp 300mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.77, "minimum": 3.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.98 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0737", "type": "HCPCS" } ], "description": "Inj, clindamycin (baxter)", "standard_charges": [ { "billing_class": "facility", "maximum": 7.07, "minimum": 4.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0739", "type": "HCPCS" } ], "description": "Injection, cabotegravir 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 18.67, "minimum": 7.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 16.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0740", "type": "HCPCS" } ], "description": "Cidofovir injection", "standard_charges": [ { "billing_class": "facility", "maximum": 815.98, "minimum": 511.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 546.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 704.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 704.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 511.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 815.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 815.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0741", "type": "HCPCS" } ], "description": "Inj, cabote rilpivir 2mg 3mg", "standard_charges": [ { "billing_class": "facility", "maximum": 62.79, "minimum": 23.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 54.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 54.22 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 39.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0742", "type": "HCPCS" } ], "description": "Inj imip 4 cilas 4 releb 2mg", "standard_charges": [ { "billing_class": "facility", "maximum": 6.78, "minimum": 4.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0743", "type": "HCPCS" } ], "description": "Cilastatin sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 19.51, "minimum": 12.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 16.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0744", "type": "HCPCS" } ], "description": "Ciprofloxacin iv", "standard_charges": [ { "billing_class": "facility", "maximum": 2.25, "minimum": 1.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.94 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0745", "type": "HCPCS" } ], "description": "Inj codeine phosphate /30 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 2.63, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0750", "type": "HCPCS" } ], "description": "Hiv prep, ftc/tdf 200/300mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.93, "minimum": 1.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0751", "type": "HCPCS" } ], "description": "Hiv prep, ftc/taf 200/25mg", "standard_charges": [ { "billing_class": "facility", "maximum": 193.2, "minimum": 71.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 166.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 166.82 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 121.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 193.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 193.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0770", "type": "HCPCS" } ], "description": "Colistimethate sodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 32.95, "minimum": 20.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.45 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 20.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0775", "type": "HCPCS" } ], "description": "Collagenase, clost hist inj", "standard_charges": [ { "billing_class": "facility", "maximum": 192.11, "minimum": 75.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 165.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 165.88 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 120.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0780", "type": "HCPCS" } ], "description": "Prochlorperazine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 7.99, "minimum": 5.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0791", "type": "HCPCS" } ], "description": "Inj crizanlizumab-tmca 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 348.72, "minimum": 129.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 301.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 301.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 218.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 348.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 348.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0795", "type": "HCPCS" } ], "description": "Corticorelin ovine triflutal", "standard_charges": [ { "billing_class": "facility", "maximum": 11.41, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0801", "type": "HCPCS" } ], "description": "Inj. acthar gel to 40 units", "standard_charges": [ { "billing_class": "facility", "maximum": 10373.42, "minimum": 4134.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4134.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8957.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8957.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6507.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10373.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10373.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0802", "type": "HCPCS" } ], "description": "Inj. (ani), up to 40 units", "standard_charges": [ { "billing_class": "facility", "maximum": 9400.58, "minimum": 3534.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3534.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8117.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8117.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5897.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9400.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9400.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0834", "type": "HCPCS" } ], "description": "Cosyntropin cortrosyn inj", "standard_charges": [ { "billing_class": "facility", "maximum": 90.6, "minimum": 56.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 78.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 78.23 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 56.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0840", "type": "HCPCS" } ], "description": "Crotalidae poly immune fab", "standard_charges": [ { "billing_class": "facility", "maximum": 4822.82, "minimum": 1828.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1828.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4164.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4164.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3025.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4822.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4822.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0841", "type": "HCPCS" } ], "description": "Inj crotalidae im f(ab')2 eq", "standard_charges": [ { "billing_class": "facility", "maximum": 2783.63, "minimum": 1045.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1045.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2403.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2403.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1746.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2783.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2783.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0850", "type": "HCPCS" } ], "description": "Cytomegalovirus imm IV /vial", "standard_charges": [ { "billing_class": "facility", "maximum": 4916.24, "minimum": 1808.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1808.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4245.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4245.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3083.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4916.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4916.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0872", "type": "HCPCS" } ], "description": "Daptomycin (xellia) unrefrig", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0873", "type": "HCPCS" } ], "description": "Inj, daptomycin (xellia)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0874", "type": "HCPCS" } ], "description": "Inj, daptomycin (baxter)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.19, "minimum": 0.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0875", "type": "HCPCS" } ], "description": "Injection, dalbavancin", "standard_charges": [ { "billing_class": "facility", "maximum": 42.28, "minimum": 15.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 36.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 26.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0877", "type": "HCPCS" } ], "description": "Inj, daptomycin (hospira)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0878", "type": "HCPCS" } ], "description": "Daptomycin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0879", "type": "HCPCS" } ], "description": "Difelikefalin, esrd on dialy", "standard_charges": [ { "billing_class": "facility", "maximum": 0.54, "minimum": 0.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0881", "type": "HCPCS" } ], "description": "Darbepoetin alfa, non-esrd", "standard_charges": [ { "billing_class": "facility", "maximum": 8.05, "minimum": 2.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.95 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0882", "type": "HCPCS" } ], "description": "Darbepoetin alfa, esrd use", "standard_charges": [ { "billing_class": "facility", "maximum": 8.05, "minimum": 2.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.95 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0883", "type": "HCPCS" } ], "description": "Argatroban nonesrd use 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 7.37, "minimum": 0.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0884", "type": "HCPCS" } ], "description": "Argatroban esrd dialysis 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.17, "minimum": 1.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0885", "type": "HCPCS" } ], "description": "Epoetin alfa, non-esrd", "standard_charges": [ { "billing_class": "facility", "maximum": 17.51, "minimum": 8.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0887", "type": "HCPCS" } ], "description": "Epoetin beta esrd use", "standard_charges": [ { "billing_class": "facility", "maximum": 3.31, "minimum": 2.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0888", "type": "HCPCS" } ], "description": "Epoetin beta non esrd", "standard_charges": [ { "billing_class": "facility", "maximum": 3.28, "minimum": 2.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0889", "type": "HCPCS" } ], "description": "Daprodustat oral 1mg esrd", "standard_charges": [ { "billing_class": "facility", "maximum": 9.15, "minimum": 9.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0890", "type": "HCPCS" } ], "description": "Peginesatide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0891", "type": "HCPCS" } ], "description": "Argatroban nonesrd (accord)", "standard_charges": [ { "billing_class": "facility", "maximum": 9.27, "minimum": 1.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0892", "type": "HCPCS" } ], "description": "Argatroban dialysis (accord)", "standard_charges": [ { "billing_class": "facility", "maximum": 12.87, "minimum": 9.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0893", "type": "HCPCS" } ], "description": "Inj, decitabine (sun pharma)", "standard_charges": [ { "billing_class": "facility", "maximum": 100.05, "minimum": 4.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0894", "type": "HCPCS" } ], "description": "Decitabine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 6.31, "minimum": 3.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.45 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0895", "type": "HCPCS" } ], "description": "Deferoxamine mesylate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 24.23, "minimum": 15.19, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.92 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 15.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0896", "type": "HCPCS" } ], "description": "Inj luspatercept-aamt 0.25mg", "standard_charges": [ { "billing_class": "facility", "maximum": 111.87, "minimum": 41.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 96.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 96.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 70.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0897", "type": "HCPCS" } ], "description": "Denosumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 74.96, "minimum": 29.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 64.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 64.72 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 47.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 74.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0898", "type": "HCPCS" } ], "description": "Argatroban nonesrd (auromed)", "standard_charges": [ { "billing_class": "facility", "maximum": 9.13, "minimum": 3.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0899", "type": "HCPCS" } ], "description": "Argatroban dialysis, auromed", "standard_charges": [ { "billing_class": "facility", "maximum": 14.28, "minimum": 9.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0911", "type": "HCPCS" } ], "description": "Inst tauro 1.35mg/hep 100u", "standard_charges": [ { "billing_class": "facility", "maximum": 23.47, "minimum": 6.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1000", "type": "HCPCS" } ], "description": "Depo-estradiol cypionate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 104.74, "minimum": 65.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 90.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 90.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 65.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 104.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1010", "type": "HCPCS" } ], "description": "Inj, methylpred acetate 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.33, "minimum": 0.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1050", "type": "HCPCS" } ], "description": "Medroxyprogesterone acetate", "standard_charges": [ { "billing_class": "facility", "maximum": 1.36, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1071", "type": "HCPCS" } ], "description": "Inj testosterone cypionate", "standard_charges": [ { "billing_class": "facility", "maximum": 0.08, "minimum": 0.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1094", "type": "HCPCS" } ], "description": "Inj dexamethasone acetate", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1095", "type": "HCPCS" } ], "description": "Injection, dexamethasone 9%", "standard_charges": [ { "billing_class": "facility", "maximum": 7.34, "minimum": 2.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84392", "type": "HCPCS" } ], "description": "Assay of urine sulfate", "standard_charges": [ { "billing_class": "facility", "maximum": 20.59, "minimum": 5.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84402", "type": "HCPCS" } ], "description": "Assay of free testosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 95.51, "minimum": 25.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84403", "type": "HCPCS" } ], "description": "Assay of total testosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 96.79, "minimum": 25.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 96.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 96.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84410", "type": "HCPCS" } ], "description": "Testosterone bioavailable", "standard_charges": [ { "billing_class": "facility", "maximum": 192.3, "minimum": 51.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84425", "type": "HCPCS" } ], "description": "Assay of vitamin b-1", "standard_charges": [ { "billing_class": "facility", "maximum": 79.61, "minimum": 21.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84430", "type": "HCPCS" } ], "description": "Assay of thiocyanate", "standard_charges": [ { "billing_class": "facility", "maximum": 43.61, "minimum": 11.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84431", "type": "HCPCS" } ], "description": "Thromboxane urine", "standard_charges": [ { "billing_class": "facility", "maximum": 131.66, "minimum": 35.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84432", "type": "HCPCS" } ], "description": "Assay of thyroglobulin", "standard_charges": [ { "billing_class": "facility", "maximum": 60.23, "minimum": 16.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84433", "type": "HCPCS" } ], "description": "Asy thiopurin s-mthyltrnsfrs", "standard_charges": [ { "billing_class": "facility", "maximum": 83.14, "minimum": 22.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84436", "type": "HCPCS" } ], "description": "Assay of total thyroxine", "standard_charges": [ { "billing_class": "facility", "maximum": 25.76, "minimum": 6.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84437", "type": "HCPCS" } ], "description": "Assay of neonatal thyroxine", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84439", "type": "HCPCS" } ], "description": "Assay of free thyroxine", "standard_charges": [ { "billing_class": "facility", "maximum": 33.83, "minimum": 9.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84442", "type": "HCPCS" } ], "description": "Assay of thyroid activity", "standard_charges": [ { "billing_class": "facility", "maximum": 55.43, "minimum": 14.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84443", "type": "HCPCS" } ], "description": "Assay thyroid stim hormone", "standard_charges": [ { "billing_class": "facility", "maximum": 63.0, "minimum": 16.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84445", "type": "HCPCS" } ], "description": "Assay of tsi globulin", "standard_charges": [ { "billing_class": "facility", "maximum": 190.73, "minimum": 50.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 190.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 190.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84446", "type": "HCPCS" } ], "description": "Assay of vitamin e", "standard_charges": [ { "billing_class": "facility", "maximum": 53.18, "minimum": 14.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84449", "type": "HCPCS" } ], "description": "Assay of transcortin", "standard_charges": [ { "billing_class": "facility", "maximum": 67.5, "minimum": 18.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84450", "type": "HCPCS" } ], "description": "Transferase (AST) (SGOT)", "standard_charges": [ { "billing_class": "facility", "maximum": 19.43, "minimum": 5.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84460", "type": "HCPCS" } ], "description": "Alanine amino (ALT) (SGPT)", "standard_charges": [ { "billing_class": "facility", "maximum": 19.88, "minimum": 5.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84466", "type": "HCPCS" } ], "description": "Assay of transferrin", "standard_charges": [ { "billing_class": "facility", "maximum": 47.85, "minimum": 12.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84478", "type": "HCPCS" } ], "description": "Assay of triglycerides", "standard_charges": [ { "billing_class": "facility", "maximum": 21.53, "minimum": 5.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84479", "type": "HCPCS" } ], "description": "Assay of thyroid (t3 or t4)", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84480", "type": "HCPCS" } ], "description": "Assay triiodothyronine (t3)", "standard_charges": [ { "billing_class": "facility", "maximum": 53.18, "minimum": 14.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84481", "type": "HCPCS" } ], "description": "Free assay (FT-3)", "standard_charges": [ { "billing_class": "facility", "maximum": 63.53, "minimum": 16.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84482", "type": "HCPCS" } ], "description": "T3 reverse", "standard_charges": [ { "billing_class": "facility", "maximum": 59.1, "minimum": 15.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84484", "type": "HCPCS" } ], "description": "Assay of troponin quant", "standard_charges": [ { "billing_class": "facility", "maximum": 46.76, "minimum": 12.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84485", "type": "HCPCS" } ], "description": "Assay duodenal fluid trypsin", "standard_charges": [ { "billing_class": "facility", "maximum": 27.0, "minimum": 7.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84488", "type": "HCPCS" } ], "description": "Test feces for trypsin", "standard_charges": [ { "billing_class": "facility", "maximum": 27.38, "minimum": 7.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84490", "type": "HCPCS" } ], "description": "Assay of feces for trypsin", "standard_charges": [ { "billing_class": "facility", "maximum": 37.24, "minimum": 9.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84510", "type": "HCPCS" } ], "description": "Assay of tyrosine", "standard_charges": [ { "billing_class": "facility", "maximum": 39.86, "minimum": 10.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1096", "type": "HCPCS" } ], "description": "Dexametha opth insert 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 306.09, "minimum": 102.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 102.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 264.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 264.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 192.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 306.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 306.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1097", "type": "HCPCS" } ], "description": "Phenylep ketorolac opth soln", "standard_charges": [ { "billing_class": "facility", "maximum": 276.12, "minimum": 96.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 96.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 276.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 276.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 262.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 262.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1100", "type": "HCPCS" } ], "description": "Dexamethasone sodium phos", "standard_charges": [ { "billing_class": "facility", "maximum": 0.3, "minimum": 0.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1110", "type": "HCPCS" } ], "description": "Inj dihydroergotamine mesylt", "standard_charges": [ { "billing_class": "facility", "maximum": 111.22, "minimum": 69.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 96.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 96.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 69.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1120", "type": "HCPCS" } ], "description": "Acetazolamid sodium injectio", "standard_charges": [ { "billing_class": "facility", "maximum": 58.59, "minimum": 36.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 50.59 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 36.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1130", "type": "HCPCS" } ], "description": "Inj diclofenac sodium 0.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1160", "type": "HCPCS" } ], "description": "Digoxin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 23.9, "minimum": 14.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.64 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1162", "type": "HCPCS" } ], "description": "Digoxin immune fab (ovine)", "standard_charges": [ { "billing_class": "facility", "maximum": 13739.65, "minimum": 5168.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5168.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11863.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11863.75 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8618.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13739.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13739.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1165", "type": "HCPCS" } ], "description": "Phenytoin sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.27, "minimum": 0.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.1 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1171", "type": "HCPCS" } ], "description": "Inj, hydromorphone, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.24, "minimum": 0.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1190", "type": "HCPCS" } ], "description": "Dexrazoxane hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 219.18, "minimum": 63.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 63.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 189.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 189.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 137.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 219.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 219.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1200", "type": "HCPCS" } ], "description": "Diphenhydramine hcl injectio", "standard_charges": [ { "billing_class": "facility", "maximum": 1.98, "minimum": 1.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1201", "type": "HCPCS" } ], "description": "Inj. cetirizine hcl 0.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 42.63, "minimum": 16.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 36.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 26.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1202", "type": "HCPCS" } ], "description": "Miglustat oral 65 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 107.32, "minimum": 77.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 77.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 107.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 107.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1203", "type": "HCPCS" } ], "description": "Inj, cipaglucosidase, 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 242.22, "minimum": 91.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 209.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 209.15 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 151.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 242.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 242.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1205", "type": "HCPCS" } ], "description": "Chlorothiazide sodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 163.85, "minimum": 102.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 141.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 141.48 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 102.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 163.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 163.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1212", "type": "HCPCS" } ], "description": "Dimethyl sulfoxide 50% 50 ML", "standard_charges": [ { "billing_class": "facility", "maximum": 1938.71, "minimum": 748.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 748.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1674.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1674.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1216.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1938.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1938.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1230", "type": "HCPCS" } ], "description": "Methadone injection", "standard_charges": [ { "billing_class": "facility", "maximum": 55.99, "minimum": 35.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 48.34 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 35.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1240", "type": "HCPCS" } ], "description": "Dimenhydrinate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 23.5, "minimum": 14.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1245", "type": "HCPCS" } ], "description": "Dipyridamole injection", "standard_charges": [ { "billing_class": "facility", "maximum": 10.49, "minimum": 6.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1250", "type": "HCPCS" } ], "description": "Inj dobutamine HCL/250 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 20.03, "minimum": 12.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 17.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1260", "type": "HCPCS" } ], "description": "Dolasetron mesylate", "standard_charges": [ { "billing_class": "facility", "maximum": 9.65, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1265", "type": "HCPCS" } ], "description": "Dopamine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2.09, "minimum": 1.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.8 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1267", "type": "HCPCS" } ], "description": "Doripenem injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.76, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1270", "type": "HCPCS" } ], "description": "Injection, doxercalciferol", "standard_charges": [ { "billing_class": "facility", "maximum": 1.03, "minimum": 0.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1290", "type": "HCPCS" } ], "description": "Ecallantide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1526.0, "minimum": 579.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 579.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1317.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1317.65 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 957.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1526.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1526.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1300", "type": "HCPCS" } ], "description": "Eculizumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 607.47, "minimum": 381.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 524.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 524.53 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 381.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 607.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 607.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1301", "type": "HCPCS" } ], "description": "Injection, edaravone, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 58.75, "minimum": 20.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 50.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 36.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1302", "type": "HCPCS" } ], "description": "Inj, sutimlimab-jome, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 49.13, "minimum": 18.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 42.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 30.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1303", "type": "HCPCS" } ], "description": "Inj., ravulizumab-cwvz 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 597.8, "minimum": 225.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 225.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 516.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 516.18 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 375.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 597.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 597.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1304", "type": "HCPCS" } ], "description": "Inj tofersen intrathec 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 420.97, "minimum": 159.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 159.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 363.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 363.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 264.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 420.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 420.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1305", "type": "HCPCS" } ], "description": "Inj, evinacumab-dgnb, 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 504.9, "minimum": 193.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 435.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 435.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 316.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 504.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 504.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1306", "type": "HCPCS" } ], "description": "Injection, inclisiran, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 33.28, "minimum": 12.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.74 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 20.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1322", "type": "HCPCS" } ], "description": "Elosulfase alfa, injection", "standard_charges": [ { "billing_class": "facility", "maximum": 796.52, "minimum": 308.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 308.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 687.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 687.77 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 499.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 796.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 796.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1323", "type": "HCPCS" } ], "description": "Inj, elranatamab-bcmm, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 481.43, "minimum": 184.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 184.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 415.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 415.7 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 302.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 481.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 481.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1324", "type": "HCPCS" } ], "description": "Enfuvirtide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2.17, "minimum": 1.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1325", "type": "HCPCS" } ], "description": "Epoprostenol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 44.55, "minimum": 27.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 38.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 27.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1327", "type": "HCPCS" } ], "description": "Eptifibatide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 68.67, "minimum": 2.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1330", "type": "HCPCS" } ], "description": "Ergonovine maleate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1335", "type": "HCPCS" } ], "description": "Ertapenem injection", "standard_charges": [ { "billing_class": "facility", "maximum": 29.84, "minimum": 18.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 25.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 18.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1364", "type": "HCPCS" } ], "description": "Erythro lactobionate /500 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 168.4, "minimum": 105.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 145.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 145.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 105.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 168.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 168.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1380", "type": "HCPCS" } ], "description": "Estradiol valerate 10 MG inj", "standard_charges": [ { "billing_class": "facility", "maximum": 21.52, "minimum": 13.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 13.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1410", "type": "HCPCS" } ], "description": "Inj estrogen conjugate 25 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 1037.69, "minimum": 392.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 392.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 896.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 896.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 650.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1037.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1037.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1411", "type": "HCPCS" } ], "description": "Inj, hemgenix, per tx dose", "standard_charges": [ { "billing_class": "facility", "maximum": 10054100.0, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3685266.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10054100.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10054100.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1412", "type": "HCPCS" } ], "description": "Inj roctavian ml 2x10^13vc g", "standard_charges": [ { "billing_class": "facility", "maximum": 31620.2, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12553.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31620.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31620.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1413", "type": "HCPCS" } ], "description": "Inj delandistrogene mox rokl", "standard_charges": [ { "billing_class": "facility", "maximum": 9002027.89, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3316462.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9002027.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9002027.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1426", "type": "HCPCS" } ], "description": "Injection, casimersen, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 520.32, "minimum": 166.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 374.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 374.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 520.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 520.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1427", "type": "HCPCS" } ], "description": "Inj. viltolarsen", "standard_charges": [ { "billing_class": "facility", "maximum": 183.41, "minimum": 131.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 131.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 131.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 183.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 183.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1428", "type": "HCPCS" } ], "description": "Inj, eteplirsen, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 520.32, "minimum": 167.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 374.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 374.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 520.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 520.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1429", "type": "HCPCS" } ], "description": "Inj golodirsen 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 520.32, "minimum": 374.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 374.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 374.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 520.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 520.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1430", "type": "HCPCS" } ], "description": "Ethanolamine oleate 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1332.37, "minimum": 508.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 508.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1150.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1150.46 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 835.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1332.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1332.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1434", "type": "HCPCS" } ], "description": "Inj, focinvez, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 8.46, "minimum": 2.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1437", "type": "HCPCS" } ], "description": "Inj. fe derisomaltose 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 56.29, "minimum": 22.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 48.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 35.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1438", "type": "HCPCS" } ], "description": "Etanercept injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2230.0, "minimum": 2143.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2230.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2230.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2143.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2143.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1439", "type": "HCPCS" } ], "description": "Inj ferric carboxymaltos 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.01, "minimum": 1.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1440", "type": "HCPCS" } ], "description": "Fecal?microbiota jslm 1 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 172.36, "minimum": 63.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 63.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 148.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 148.82 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 108.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 172.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 172.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1442", "type": "HCPCS" } ], "description": "Inj filgrastim excl biosimil", "standard_charges": [ { "billing_class": "facility", "maximum": 2.66, "minimum": 1.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1443", "type": "HCPCS" } ], "description": "Inj ferric pyrophosphate cit", "standard_charges": [ { "billing_class": "facility", "maximum": 0.07, "minimum": 0.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1444", "type": "HCPCS" } ], "description": "Fe pyro cit pow 0.1 mg iron", "standard_charges": [ { "billing_class": "facility", "maximum": 0.07, "minimum": 0.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1445", "type": "HCPCS" } ], "description": "Inj triferic avnu 0.1mg iron", "standard_charges": [ { "billing_class": "facility", "maximum": 0.42, "minimum": 0.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1447", "type": "HCPCS" } ], "description": "Inj tbo filgrastim 1 microg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.08, "minimum": 0.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.94 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1448", "type": "HCPCS" } ], "description": "Injection, trilaciclib, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 14.55, "minimum": 5.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1449", "type": "HCPCS" } ], "description": "Inj eflapegrastim-xnst 0.1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 60.0, "minimum": 20.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 51.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 37.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1450", "type": "HCPCS" } ], "description": "Fluconazole", "standard_charges": [ { "billing_class": "facility", "maximum": 6.48, "minimum": 4.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.59 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1451", "type": "HCPCS" } ], "description": "Fomepizole, 15 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 29.09, "minimum": 6.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 29.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1453", "type": "HCPCS" } ], "description": "Fosaprepitant injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.33, "minimum": 0.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1454", "type": "HCPCS" } ], "description": "Inj fosnetupitant, palonoset", "standard_charges": [ { "billing_class": "facility", "maximum": 1783.45, "minimum": 575.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 575.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1539.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1539.95 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1118.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1783.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1783.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1455", "type": "HCPCS" } ], "description": "Foscarnet sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 103.74, "minimum": 65.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 89.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 89.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 65.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 103.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 103.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1456", "type": "HCPCS" } ], "description": "Inj, fosaprepitant (teva)", "standard_charges": [ { "billing_class": "facility", "maximum": 1.19, "minimum": 0.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1457", "type": "HCPCS" } ], "description": "Gallium nitrate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.5, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1458", "type": "HCPCS" } ], "description": "Galsulfase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1314.13, "minimum": 508.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 508.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1134.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1134.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 824.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1314.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1314.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1459", "type": "HCPCS" } ], "description": "Inj IVIG privigen 500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 133.55, "minimum": 50.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 115.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 115.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 83.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 133.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 133.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1460", "type": "HCPCS" } ], "description": "Gamma globulin 1 CC inj", "standard_charges": [ { "billing_class": "facility", "maximum": 133.93, "minimum": 49.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 49.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 115.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 115.64 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 84.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 133.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 133.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1551", "type": "HCPCS" } ], "description": "Inj cutaquig 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 39.32, "minimum": 14.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 33.95 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 24.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1554", "type": "HCPCS" } ], "description": "Inj. asceniv", "standard_charges": [ { "billing_class": "facility", "maximum": 1341.37, "minimum": 496.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 496.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1158.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1158.23 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 841.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1341.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1341.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1555", "type": "HCPCS" } ], "description": "Inj cuvitru, 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 45.01, "minimum": 16.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 38.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 28.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1556", "type": "HCPCS" } ], "description": "Inj, imm glob bivigam, 500mg", "standard_charges": [ { "billing_class": "facility", "maximum": 207.67, "minimum": 77.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 179.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 179.31 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 130.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 207.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 207.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1557", "type": "HCPCS" } ], "description": "Gammaplex injection", "standard_charges": [ { "billing_class": "facility", "maximum": 153.85, "minimum": 63.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 63.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 132.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 132.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 96.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 153.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 153.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1558", "type": "HCPCS" } ], "description": "Inj. xembify, 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 38.64, "minimum": 14.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 33.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 24.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1559", "type": "HCPCS" } ], "description": "Hizentra injection", "standard_charges": [ { "billing_class": "facility", "maximum": 36.96, "minimum": 14.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 31.92 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 23.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1560", "type": "HCPCS" } ], "description": "Gamma globulin > 10 CC inj", "standard_charges": [ { "billing_class": "facility", "maximum": 1339.17, "minimum": 170.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 170.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1156.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1156.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 840.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1339.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1339.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1561", "type": "HCPCS" } ], "description": "Gamunex-c/gammaked", "standard_charges": [ { "billing_class": "facility", "maximum": 132.82, "minimum": 48.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 114.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 114.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 83.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 132.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1562", "type": "HCPCS" } ], "description": "Vivaglobin, inj", "standard_charges": [ { "billing_class": "facility", "maximum": 24.55, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1566", "type": "HCPCS" } ], "description": "Immune globulin, powder", "standard_charges": [ { "billing_class": "facility", "maximum": 220.68, "minimum": 78.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 190.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 190.55 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 138.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 220.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 220.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1568", "type": "HCPCS" } ], "description": "Octagam injection", "standard_charges": [ { "billing_class": "facility", "maximum": 133.6, "minimum": 47.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 115.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 115.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 83.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 133.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 133.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1569", "type": "HCPCS" } ], "description": "Gammagard liquid injection", "standard_charges": [ { "billing_class": "facility", "maximum": 125.91, "minimum": 45.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 108.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 108.72 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 78.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 125.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 125.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1570", "type": "HCPCS" } ], "description": "Ganciclovir sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 77.89, "minimum": 48.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 67.25 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 48.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1571", "type": "HCPCS" } ], "description": "HepaGam B IM injection", "standard_charges": [ { "billing_class": "facility", "maximum": 178.7, "minimum": 66.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 154.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 154.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 112.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 178.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 178.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1572", "type": "HCPCS" } ], "description": "Flebogamma injection", "standard_charges": [ { "billing_class": "facility", "maximum": 123.88, "minimum": 120.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 123.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 123.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 120.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 120.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1573", "type": "HCPCS" } ], "description": "Hepagam B intravenous, inj", "standard_charges": [ { "billing_class": "facility", "maximum": 178.7, "minimum": 66.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 154.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 154.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 112.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 178.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 178.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1574", "type": "HCPCS" } ], "description": "Inj, ganciclovir (exela)", "standard_charges": [ { "billing_class": "facility", "maximum": 162.6, "minimum": 117.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 117.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 117.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 162.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 162.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1575", "type": "HCPCS" } ], "description": "Hyqvia 100mg immuneglobulin", "standard_charges": [ { "billing_class": "facility", "maximum": 47.94, "minimum": 18.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 41.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 30.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1576", "type": "HCPCS" } ], "description": "Inj, panzyga, 500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 187.26, "minimum": 73.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 161.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 161.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 117.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 187.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 187.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1580", "type": "HCPCS" } ], "description": "Garamycin gentamicin inj", "standard_charges": [ { "billing_class": "facility", "maximum": 6.69, "minimum": 4.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.78 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1595", "type": "HCPCS" } ], "description": "Injection glatiramer acetate", "standard_charges": [ { "billing_class": "facility", "maximum": 464.95, "minimum": 134.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 134.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 134.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 464.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 464.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1596", "type": "HCPCS" } ], "description": "Inj, glycopyrrolate, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.57, "minimum": 0.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84512", "type": "HCPCS" } ], "description": "Assay of troponin qual", "standard_charges": [ { "billing_class": "facility", "maximum": 37.84, "minimum": 10.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84520", "type": "HCPCS" } ], "description": "Assay of urea nitrogen", "standard_charges": [ { "billing_class": "facility", "maximum": 14.81, "minimum": 3.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84525", "type": "HCPCS" } ], "description": "Urea nitrogen semi-quant", "standard_charges": [ { "billing_class": "facility", "maximum": 19.24, "minimum": 5.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84540", "type": "HCPCS" } ], "description": "Assay of urine/urea-n", "standard_charges": [ { "billing_class": "facility", "maximum": 20.85, "minimum": 5.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84545", "type": "HCPCS" } ], "description": "Urea-N clearance test", "standard_charges": [ { "billing_class": "facility", "maximum": 27.0, "minimum": 7.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84550", "type": "HCPCS" } ], "description": "Assay of blood/uric acid", "standard_charges": [ { "billing_class": "facility", "maximum": 16.95, "minimum": 4.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84560", "type": "HCPCS" } ], "description": "Assay of urine/uric acid", "standard_charges": [ { "billing_class": "facility", "maximum": 19.05, "minimum": 5.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84577", "type": "HCPCS" } ], "description": "Assay of feces/urobilinogen", "standard_charges": [ { "billing_class": "facility", "maximum": 63.0, "minimum": 16.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84578", "type": "HCPCS" } ], "description": "Test urine urobilinogen", "standard_charges": [ { "billing_class": "facility", "maximum": 16.76, "minimum": 4.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84580", "type": "HCPCS" } ], "description": "Assay of urine urobilinogen", "standard_charges": [ { "billing_class": "facility", "maximum": 35.81, "minimum": 9.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84583", "type": "HCPCS" } ], "description": "Assay of urine urobilinogen", "standard_charges": [ { "billing_class": "facility", "maximum": 22.69, "minimum": 6.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84585", "type": "HCPCS" } ], "description": "Assay of urine vma", "standard_charges": [ { "billing_class": "facility", "maximum": 58.13, "minimum": 15.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84586", "type": "HCPCS" } ], "description": "Assay of vip", "standard_charges": [ { "billing_class": "facility", "maximum": 132.49, "minimum": 35.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 132.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84588", "type": "HCPCS" } ], "description": "Assay of vasopressin", "standard_charges": [ { "billing_class": "facility", "maximum": 127.28, "minimum": 33.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84590", "type": "HCPCS" } ], "description": "Assay of vitamin a", "standard_charges": [ { "billing_class": "facility", "maximum": 43.54, "minimum": 11.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84591", "type": "HCPCS" } ], "description": "Assay Of Nos Vitamin", "standard_charges": [ { "billing_class": "facility", "maximum": 63.98, "minimum": 17.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84597", "type": "HCPCS" } ], "description": "Assay of vitamin k", "standard_charges": [ { "billing_class": "facility", "maximum": 51.45, "minimum": 13.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84600", "type": "HCPCS" } ], "description": "Assay of volatiles", "standard_charges": [ { "billing_class": "facility", "maximum": 64.16, "minimum": 17.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84620", "type": "HCPCS" } ], "description": "Xylose tolerance test", "standard_charges": [ { "billing_class": "facility", "maximum": 48.41, "minimum": 12.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84630", "type": "HCPCS" } ], "description": "Assay of zinc", "standard_charges": [ { "billing_class": "facility", "maximum": 42.71, "minimum": 11.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84681", "type": "HCPCS" } ], "description": "Assay of c-peptide", "standard_charges": [ { "billing_class": "facility", "maximum": 78.04, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84702", "type": "HCPCS" } ], "description": "Chorionic gonadotropin test", "standard_charges": [ { "billing_class": "facility", "maximum": 56.44, "minimum": 15.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84703", "type": "HCPCS" } ], "description": "Chorionic gonadotropin assay", "standard_charges": [ { "billing_class": "facility", "maximum": 28.2, "minimum": 7.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84704", "type": "HCPCS" } ], "description": "Hcg free betachain test", "standard_charges": [ { "billing_class": "facility", "maximum": 57.34, "minimum": 15.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84830", "type": "HCPCS" } ], "description": "Ovulation tests", "standard_charges": [ { "billing_class": "facility", "maximum": 47.63, "minimum": 12.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85002", "type": "HCPCS" } ], "description": "Bleeding time test", "standard_charges": [ { "billing_class": "facility", "maximum": 18.08, "minimum": 4.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85004", "type": "HCPCS" } ], "description": "Automated diff wbc count", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85007", "type": "HCPCS" } ], "description": "Bl smear w/diff wbc count", "standard_charges": [ { "billing_class": "facility", "maximum": 14.25, "minimum": 3.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85008", "type": "HCPCS" } ], "description": "Bl smear w/o diff wbc count", "standard_charges": [ { "billing_class": "facility", "maximum": 12.86, "minimum": 3.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85009", "type": "HCPCS" } ], "description": "Manual diff wbc count b-coat", "standard_charges": [ { "billing_class": "facility", "maximum": 19.01, "minimum": 5.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85013", "type": "HCPCS" } ], "description": "Spun microhematocrit", "standard_charges": [ { "billing_class": "facility", "maximum": 26.25, "minimum": 7.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85014", "type": "HCPCS" } ], "description": "Hematocrit", "standard_charges": [ { "billing_class": "facility", "maximum": 8.89, "minimum": 2.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85018", "type": "HCPCS" } ], "description": "Hemoglobin", "standard_charges": [ { "billing_class": "facility", "maximum": 8.89, "minimum": 2.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85025", "type": "HCPCS" } ], "description": "Complete cbc w/auto diff wbc", "standard_charges": [ { "billing_class": "facility", "maximum": 29.14, "minimum": 7.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85027", "type": "HCPCS" } ], "description": "Complete cbc automated", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85032", "type": "HCPCS" } ], "description": "Manual cell count each", "standard_charges": [ { "billing_class": "facility", "maximum": 16.16, "minimum": 4.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85041", "type": "HCPCS" } ], "description": "Automated rbc count", "standard_charges": [ { "billing_class": "facility", "maximum": 11.33, "minimum": 3.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85044", "type": "HCPCS" } ], "description": "Manual reticulocyte count", "standard_charges": [ { "billing_class": "facility", "maximum": 16.16, "minimum": 4.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85045", "type": "HCPCS" } ], "description": "Automated reticulocyte count", "standard_charges": [ { "billing_class": "facility", "maximum": 14.96, "minimum": 3.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85046", "type": "HCPCS" } ], "description": "Reticyte/hgb concentrate", "standard_charges": [ { "billing_class": "facility", "maximum": 20.89, "minimum": 5.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85048", "type": "HCPCS" } ], "description": "Automated leukocyte count", "standard_charges": [ { "billing_class": "facility", "maximum": 9.53, "minimum": 2.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85049", "type": "HCPCS" } ], "description": "Automated platelet count", "standard_charges": [ { "billing_class": "facility", "maximum": 16.8, "minimum": 4.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85055", "type": "HCPCS" } ], "description": "Reticulated platelet assay", "standard_charges": [ { "billing_class": "facility", "maximum": 134.03, "minimum": 35.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 134.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 134.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85060", "type": "HCPCS" } ], "description": "Blood smear interpretation", "standard_charges": [ { "billing_class": "facility", "maximum": 90.23, "minimum": 90.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85097", "type": "HCPCS" } ], "description": "Bone marrow interpretation", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85130", "type": "HCPCS" } ], "description": "Chromogenic substrate assay", "standard_charges": [ { "billing_class": "facility", "maximum": 44.59, "minimum": 11.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85170", "type": "HCPCS" } ], "description": "Blood clot retraction", "standard_charges": [ { "billing_class": "facility", "maximum": 61.13, "minimum": 16.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85370", "type": "HCPCS" } ], "description": "Fibrinogen test", "standard_charges": [ { "billing_class": "facility", "maximum": 46.61, "minimum": 12.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85378", "type": "HCPCS" } ], "description": "Fibrin degrade semiquant", "standard_charges": [ { "billing_class": "facility", "maximum": 36.45, "minimum": 9.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85379", "type": "HCPCS" } ], "description": "Fibrin degradation quant", "standard_charges": [ { "billing_class": "facility", "maximum": 38.18, "minimum": 10.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85380", "type": "HCPCS" } ], "description": "Fibrin degradj d-dimer", "standard_charges": [ { "billing_class": "facility", "maximum": 38.18, "minimum": 10.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85384", "type": "HCPCS" } ], "description": "Fibrinogen activity", "standard_charges": [ { "billing_class": "facility", "maximum": 36.45, "minimum": 9.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85385", "type": "HCPCS" } ], "description": "Fibrinogen antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 54.23, "minimum": 14.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85390", "type": "HCPCS" } ], "description": "Fibrinolysins screen i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 58.05, "minimum": 15.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85396", "type": "HCPCS" } ], "description": "Clotting assay whole blood", "standard_charges": [ { "billing_class": "facility", "maximum": 72.45, "minimum": 72.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85397", "type": "HCPCS" } ], "description": "Clotting funct activity", "standard_charges": [ { "billing_class": "facility", "maximum": 115.73, "minimum": 30.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 115.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 115.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85400", "type": "HCPCS" } ], "description": "Fibrinolytic plasmin", "standard_charges": [ { "billing_class": "facility", "maximum": 28.91, "minimum": 7.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85410", "type": "HCPCS" } ], "description": "Fibrinolytic antiplasmin", "standard_charges": [ { "billing_class": "facility", "maximum": 28.91, "minimum": 7.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85415", "type": "HCPCS" } ], "description": "Fibrinolytic plasminogen", "standard_charges": [ { "billing_class": "facility", "maximum": 64.46, "minimum": 17.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85420", "type": "HCPCS" } ], "description": "Fibrinolytic plasminogen", "standard_charges": [ { "billing_class": "facility", "maximum": 24.49, "minimum": 6.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1597", "type": "HCPCS" } ], "description": "Inj glycopyrrolate, glyrx-pf", "standard_charges": [ { "billing_class": "facility", "maximum": 5.31, "minimum": 3.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1598", "type": "HCPCS" } ], "description": "Inj glycopyrrolate fres kabi", "standard_charges": [ { "billing_class": "facility", "maximum": 5.47, "minimum": 3.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1599", "type": "HCPCS" } ], "description": "Ivig non-lyophilized, NOS", "standard_charges": [ { "billing_class": "facility", "maximum": 348.66, "minimum": 348.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 348.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 348.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1600", "type": "HCPCS" } ], "description": "Gold sodium thiomaleate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 35.93, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1602", "type": "HCPCS" } ], "description": "Golimumab for iv use 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 28.56, "minimum": 11.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1610", "type": "HCPCS" } ], "description": "Glucagon hydrochloride/1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 499.13, "minimum": 182.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 182.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 430.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 430.98 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 313.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 499.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 499.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1611", "type": "HCPCS" } ], "description": "Inj glucagon hcl, fresenius", "standard_charges": [ { "billing_class": "facility", "maximum": 303.28, "minimum": 148.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 148.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 261.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 261.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 190.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 303.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 303.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1626", "type": "HCPCS" } ], "description": "Granisetron hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.62, "minimum": 0.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1627", "type": "HCPCS" } ], "description": "Inj, granisetron, xr, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 14.93, "minimum": 4.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1628", "type": "HCPCS" } ], "description": "Inj., guselkumab, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 199.24, "minimum": 75.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 172.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 172.04 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 124.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 199.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 199.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1630", "type": "HCPCS" } ], "description": "Haloperidol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.28, "minimum": 2.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1631", "type": "HCPCS" } ], "description": "Haloperidol decanoate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 15.04, "minimum": 9.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1632", "type": "HCPCS" } ], "description": "Inj., brexanolone, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 242.27, "minimum": 174.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 174.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 174.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 242.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 242.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1640", "type": "HCPCS" } ], "description": "Hemin, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 89.76, "minimum": 34.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 77.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 56.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 89.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 89.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1642", "type": "HCPCS" } ], "description": "Inj heparin sodium per 10 u", "standard_charges": [ { "billing_class": "facility", "maximum": 0.05, "minimum": 0.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1643", "type": "HCPCS" } ], "description": "Inj heparin, pfizer, 1000u", "standard_charges": [ { "billing_class": "facility", "maximum": 9.54, "minimum": 5.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.24 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1644", "type": "HCPCS" } ], "description": "Inj heparin sodium per 1000u", "standard_charges": [ { "billing_class": "facility", "maximum": 0.54, "minimum": 0.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1645", "type": "HCPCS" } ], "description": "Dalteparin sodium", "standard_charges": [ { "billing_class": "facility", "maximum": 37.56, "minimum": 23.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 32.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 23.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1650", "type": "HCPCS" } ], "description": "Inj enoxaparin sodium", "standard_charges": [ { "billing_class": "facility", "maximum": 1.52, "minimum": 0.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.31 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1652", "type": "HCPCS" } ], "description": "Fondaparinux sodium", "standard_charges": [ { "billing_class": "facility", "maximum": 1.82, "minimum": 1.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1655", "type": "HCPCS" } ], "description": "Tinzaparin sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 9.65, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1670", "type": "HCPCS" } ], "description": "Tetanus immune globulin inj", "standard_charges": [ { "billing_class": "facility", "maximum": 1550.31, "minimum": 593.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 593.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1338.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1338.64 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 972.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1550.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1550.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1720", "type": "HCPCS" } ], "description": "Hydrocortisone sodium succ i", "standard_charges": [ { "billing_class": "facility", "maximum": 56.75, "minimum": 35.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 49.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 35.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1726", "type": "HCPCS" } ], "description": "Makena, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 45.98, "minimum": 37.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 45.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1729", "type": "HCPCS" } ], "description": "Inj hydroxyprogst capoat nos", "standard_charges": [ { "billing_class": "facility", "maximum": 92.49, "minimum": 31.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 31.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1738", "type": "HCPCS" } ], "description": "Inj. meloxicam 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 10.19, "minimum": 7.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1740", "type": "HCPCS" } ], "description": "Ibandronate sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 68.73, "minimum": 43.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 59.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 59.34 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 43.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1741", "type": "HCPCS" } ], "description": "Ibuprofen injection", "standard_charges": [ { "billing_class": "facility", "maximum": 8.05, "minimum": 5.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.95 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1742", "type": "HCPCS" } ], "description": "Ibutilide fumarate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 698.02, "minimum": 172.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 172.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 698.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 698.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 506.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 506.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1743", "type": "HCPCS" } ], "description": "Idursulfase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1469.42, "minimum": 558.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 558.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1268.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1268.79 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 921.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1469.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1469.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1744", "type": "HCPCS" } ], "description": "Icatibant injection", "standard_charges": [ { "billing_class": "facility", "maximum": 366.01, "minimum": 218.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 218.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 218.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 366.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 366.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1745", "type": "HCPCS" } ], "description": "Infliximab not biosimil 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 82.74, "minimum": 31.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 51.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85421", "type": "HCPCS" } ], "description": "Fibrinolytic plasminogen", "standard_charges": [ { "billing_class": "facility", "maximum": 38.18, "minimum": 10.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85441", "type": "HCPCS" } ], "description": "Heinz bodies direct", "standard_charges": [ { "billing_class": "facility", "maximum": 15.75, "minimum": 4.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85445", "type": "HCPCS" } ], "description": "Heinz bodies induced", "standard_charges": [ { "billing_class": "facility", "maximum": 25.58, "minimum": 6.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85460", "type": "HCPCS" } ], "description": "Hemoglobin fetal", "standard_charges": [ { "billing_class": "facility", "maximum": 28.99, "minimum": 7.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85461", "type": "HCPCS" } ], "description": "Hemoglobin fetal", "standard_charges": [ { "billing_class": "facility", "maximum": 35.1, "minimum": 9.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85475", "type": "HCPCS" } ], "description": "Hemolysin acid", "standard_charges": [ { "billing_class": "facility", "maximum": 33.26, "minimum": 8.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85520", "type": "HCPCS" } ], "description": "Heparin assay", "standard_charges": [ { "billing_class": "facility", "maximum": 49.09, "minimum": 13.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85525", "type": "HCPCS" } ], "description": "Heparin neutralization", "standard_charges": [ { "billing_class": "facility", "maximum": 44.4, "minimum": 11.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85530", "type": "HCPCS" } ], "description": "Heparin-protamine tolerance", "standard_charges": [ { "billing_class": "facility", "maximum": 49.09, "minimum": 13.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85536", "type": "HCPCS" } ], "description": "Iron Stain Peripheral Blood", "standard_charges": [ { "billing_class": "facility", "maximum": 25.8, "minimum": 6.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85540", "type": "HCPCS" } ], "description": "Wbc alkaline phosphatase", "standard_charges": [ { "billing_class": "facility", "maximum": 32.25, "minimum": 8.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85547", "type": "HCPCS" } ], "description": "RBC mechanical fragility", "standard_charges": [ { "billing_class": "facility", "maximum": 32.25, "minimum": 8.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85549", "type": "HCPCS" } ], "description": "Muramidase", "standard_charges": [ { "billing_class": "facility", "maximum": 70.31, "minimum": 18.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85555", "type": "HCPCS" } ], "description": "RBC osmotic fragility", "standard_charges": [ { "billing_class": "facility", "maximum": 28.01, "minimum": 7.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85557", "type": "HCPCS" } ], "description": "RBC osmotic fragility", "standard_charges": [ { "billing_class": "facility", "maximum": 50.1, "minimum": 13.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85576", "type": "HCPCS" } ], "description": "Blood platelet aggregation", "standard_charges": [ { "billing_class": "facility", "maximum": 93.41, "minimum": 24.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85597", "type": "HCPCS" } ], "description": "Phospholipid pltlt neutraliz", "standard_charges": [ { "billing_class": "facility", "maximum": 67.43, "minimum": 17.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85598", "type": "HCPCS" } ], "description": "Hexagnal phosph pltlt neutrl", "standard_charges": [ { "billing_class": "facility", "maximum": 67.43, "minimum": 17.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85610", "type": "HCPCS" } ], "description": "Prothrombin time", "standard_charges": [ { "billing_class": "facility", "maximum": 16.09, "minimum": 4.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85611", "type": "HCPCS" } ], "description": "Prothrombin test", "standard_charges": [ { "billing_class": "facility", "maximum": 14.78, "minimum": 3.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85612", "type": "HCPCS" } ], "description": "Viper venom prothrombin time", "standard_charges": [ { "billing_class": "facility", "maximum": 65.59, "minimum": 17.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85613", "type": "HCPCS" } ], "description": "Russell viper venom diluted", "standard_charges": [ { "billing_class": "facility", "maximum": 35.93, "minimum": 9.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85635", "type": "HCPCS" } ], "description": "Reptilase test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.94, "minimum": 9.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85651", "type": "HCPCS" } ], "description": "Rbc sed rate nonautomated", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85652", "type": "HCPCS" } ], "description": "Rbc sed rate automated", "standard_charges": [ { "billing_class": "facility", "maximum": 10.13, "minimum": 2.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85660", "type": "HCPCS" } ], "description": "RBC sickle cell test", "standard_charges": [ { "billing_class": "facility", "maximum": 20.66, "minimum": 5.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85670", "type": "HCPCS" } ], "description": "Thrombin time plasma", "standard_charges": [ { "billing_class": "facility", "maximum": 21.64, "minimum": 5.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85675", "type": "HCPCS" } ], "description": "Thrombin time titer", "standard_charges": [ { "billing_class": "facility", "maximum": 25.69, "minimum": 6.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85705", "type": "HCPCS" } ], "description": "Thromboplastin inhibition", "standard_charges": [ { "billing_class": "facility", "maximum": 36.11, "minimum": 9.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85730", "type": "HCPCS" } ], "description": "Thromboplastin time partial", "standard_charges": [ { "billing_class": "facility", "maximum": 22.54, "minimum": 6.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1746", "type": "HCPCS" } ], "description": "Inj., ibalizumab-uiyk, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 209.02, "minimum": 79.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 180.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 180.48 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 131.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 209.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 209.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1747", "type": "HCPCS" } ], "description": "Inj, spesolimab-sbzo, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 166.48, "minimum": 65.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 65.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 143.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 143.75 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 104.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 166.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 166.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1748", "type": "HCPCS" } ], "description": "Inj, zymfentra, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 707.93, "minimum": 99.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 99.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 611.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 611.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 444.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 707.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 707.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1749", "type": "HCPCS" } ], "description": "Inj, iloprost, 0.1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 17.89, "minimum": 12.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1750", "type": "HCPCS" } ], "description": "Inj iron dextran", "standard_charges": [ { "billing_class": "facility", "maximum": 47.15, "minimum": 18.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 40.72 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 29.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1756", "type": "HCPCS" } ], "description": "Iron sucrose injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.62, "minimum": 0.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1786", "type": "HCPCS" } ], "description": "Imuglucerase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 117.56, "minimum": 43.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 101.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 101.51 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 73.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 117.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1790", "type": "HCPCS" } ], "description": "Droperidol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 33.03, "minimum": 22.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1800", "type": "HCPCS" } ], "description": "Propranolol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 27.37, "minimum": 22.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1805", "type": "HCPCS" } ], "description": "Inj, esmolol hcl, 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.57, "minimum": 0.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1806", "type": "HCPCS" } ], "description": "Inj esmolol hcl wg crit care", "standard_charges": [ { "billing_class": "facility", "maximum": 0.98, "minimum": 0.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1811", "type": "HCPCS" } ], "description": "Fiasp for insulin pump use", "standard_charges": [ { "billing_class": "facility", "maximum": 21.41, "minimum": 13.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 13.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1812", "type": "HCPCS" } ], "description": "Inj. Insulin (fiasp)", "standard_charges": [ { "billing_class": "facility", "maximum": 5.2, "minimum": 3.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1813", "type": "HCPCS" } ], "description": "Lyumjev for insulin pump use", "standard_charges": [ { "billing_class": "facility", "maximum": 41.95, "minimum": 26.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 36.22 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 26.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1814", "type": "HCPCS" } ], "description": "Inj. insulin (lyumjev)", "standard_charges": [ { "billing_class": "facility", "maximum": 5.42, "minimum": 3.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1815", "type": "HCPCS" } ], "description": "Insulin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.52, "minimum": 0.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1817", "type": "HCPCS" } ], "description": "Insulin for insulin pump use", "standard_charges": [ { "billing_class": "facility", "maximum": 6.45, "minimum": 4.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.57 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1823", "type": "HCPCS" } ], "description": "Inj. inebilizumab-cdon, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1312.72, "minimum": 495.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 495.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1133.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1133.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 823.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1312.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1312.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1826", "type": "HCPCS" } ], "description": "Interferon Beta-1A inj", "standard_charges": [ { "billing_class": "facility", "maximum": 5970.51, "minimum": 4835.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4835.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4835.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5970.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5970.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1830", "type": "HCPCS" } ], "description": "Interferon beta-1b / .25 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 1662.71, "minimum": 1327.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1662.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1662.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1327.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1327.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1833", "type": "HCPCS" } ], "description": "Injection, isavuconazonium", "standard_charges": [ { "billing_class": "facility", "maximum": 2.68, "minimum": 1.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1835", "type": "HCPCS" } ], "description": "Itraconazole injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2464.96, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2464.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2464.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1836", "type": "HCPCS" } ], "description": "Inj, metronidazole, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.08, "minimum": 0.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1885", "type": "HCPCS" } ], "description": "Ketorolac tromethamine inj", "standard_charges": [ { "billing_class": "facility", "maximum": 2.03, "minimum": 0.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1920", "type": "HCPCS" } ], "description": "Inj, labetalol hcl, 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.79, "minimum": 0.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1921", "type": "HCPCS" } ], "description": "Inj labetalol hcl hikma, 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.74, "minimum": 2.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.23 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1930", "type": "HCPCS" } ], "description": "Lanreotide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 121.9, "minimum": 34.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 105.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 105.25 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 76.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 121.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 121.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1931", "type": "HCPCS" } ], "description": "Laronidase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 104.66, "minimum": 39.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 90.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 90.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 65.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 104.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1932", "type": "HCPCS" } ], "description": "Inj, lanreotide, (cipla) 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 83.14, "minimum": 29.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.79 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 52.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1939", "type": "HCPCS" } ], "description": "Inj, bumetanide, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.57, "minimum": 0.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1940", "type": "HCPCS" } ], "description": "Furosemide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.06, "minimum": 0.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1941", "type": "HCPCS" } ], "description": "Inj, furoscix, 20 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 770.26, "minimum": 554.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 554.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 554.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 770.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 770.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85732", "type": "HCPCS" } ], "description": "Thromboplastin time partial", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "85810", "type": "HCPCS" } ], "description": "Blood viscosity examination", "standard_charges": [ { "billing_class": "facility", "maximum": 43.76, "minimum": 11.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86000", "type": "HCPCS" } ], "description": "Agglutinins febrile antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 26.18, "minimum": 6.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86001", "type": "HCPCS" } ], "description": "Allergen Specific Igg", "standard_charges": [ { "billing_class": "facility", "maximum": 29.33, "minimum": 7.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86003", "type": "HCPCS" } ], "description": "Allergen specific IgE", "standard_charges": [ { "billing_class": "facility", "maximum": 19.58, "minimum": 5.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86005", "type": "HCPCS" } ], "description": "Allergen specific IgE", "standard_charges": [ { "billing_class": "facility", "maximum": 29.89, "minimum": 7.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86008", "type": "HCPCS" } ], "description": "Allg spec ige recomb ea", "standard_charges": [ { "billing_class": "facility", "maximum": 67.24, "minimum": 17.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86015", "type": "HCPCS" } ], "description": "Actin antibody each", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86021", "type": "HCPCS" } ], "description": "WBC antibody identification", "standard_charges": [ { "billing_class": "facility", "maximum": 56.44, "minimum": 15.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86022", "type": "HCPCS" } ], "description": "Platelet antibodies", "standard_charges": [ { "billing_class": "facility", "maximum": 68.89, "minimum": 18.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86023", "type": "HCPCS" } ], "description": "Immunoglobulin assay", "standard_charges": [ { "billing_class": "facility", "maximum": 46.73, "minimum": 12.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86036", "type": "HCPCS" } ], "description": "Anca screen each antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86037", "type": "HCPCS" } ], "description": "Anca titer each antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86038", "type": "HCPCS" } ], "description": "Antinuclear antibodies", "standard_charges": [ { "billing_class": "facility", "maximum": 45.34, "minimum": 12.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86039", "type": "HCPCS" } ], "description": "Antinuclear antibodies (ANA)", "standard_charges": [ { "billing_class": "facility", "maximum": 41.85, "minimum": 11.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86041", "type": "HCPCS" } ], "description": "Acetylcholn rcptr bndng antb", "standard_charges": [ { "billing_class": "facility", "maximum": 69.0, "minimum": 18.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86042", "type": "HCPCS" } ], "description": "Acetylcholn rcptr blckg antb", "standard_charges": [ { "billing_class": "facility", "maximum": 69.0, "minimum": 18.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86043", "type": "HCPCS" } ], "description": "Acetylcholn rcptr modlg antb", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86051", "type": "HCPCS" } ], "description": "Aquaporin-4 antb elisa", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86052", "type": "HCPCS" } ], "description": "Aquaporin-4 antb cba each", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86053", "type": "HCPCS" } ], "description": "Aqaprn-4 antb flo cytmtry ea", "standard_charges": [ { "billing_class": "facility", "maximum": 141.49, "minimum": 37.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 141.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 141.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86060", "type": "HCPCS" } ], "description": "Antistreptolysin o titer", "standard_charges": [ { "billing_class": "facility", "maximum": 27.38, "minimum": 7.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86063", "type": "HCPCS" } ], "description": "Antistreptolysin o screen", "standard_charges": [ { "billing_class": "facility", "maximum": 21.64, "minimum": 5.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86077", "type": "HCPCS" } ], "description": "Phys blood bank serv xmatch", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86078", "type": "HCPCS" } ], "description": "Phys blood bank serv reactj", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86079", "type": "HCPCS" } ], "description": "Phys blood bank serv authrj", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86140", "type": "HCPCS" } ], "description": "C-reactive protein", "standard_charges": [ { "billing_class": "facility", "maximum": 19.43, "minimum": 5.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86141", "type": "HCPCS" } ], "description": "C-reactive protein hs", "standard_charges": [ { "billing_class": "facility", "maximum": 48.56, "minimum": 12.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86146", "type": "HCPCS" } ], "description": "Beta-2 glycoprotein antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 95.44, "minimum": 25.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86147", "type": "HCPCS" } ], "description": "Cardiolipin antibody ea ig", "standard_charges": [ { "billing_class": "facility", "maximum": 95.44, "minimum": 25.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1943", "type": "HCPCS" } ], "description": "Inj., aristada initio, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 8.48, "minimum": 3.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1944", "type": "HCPCS" } ], "description": "Aripirazole lauroxil 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 8.75, "minimum": 3.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1945", "type": "HCPCS" } ], "description": "Lepirudin", "standard_charges": [ { "billing_class": "facility", "maximum": 393.6, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 393.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 393.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1950", "type": "HCPCS" } ], "description": "Leuprolide acetate /3.75 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4516.97, "minimum": 1730.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1730.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3900.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3900.27 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2833.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4516.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4516.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1951", "type": "HCPCS" } ], "description": "Inj fensolvi 0.25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 369.86, "minimum": 140.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 140.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 319.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 319.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 232.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 369.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 369.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1952", "type": "HCPCS" } ], "description": "Leuprolide inj, camcevi, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 151.52, "minimum": 78.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 130.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 130.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 95.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 151.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 151.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1953", "type": "HCPCS" } ], "description": "Levetiracetam injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.14, "minimum": 0.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1954", "type": "HCPCS" } ], "description": "Leuprolide depot cipla 7.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 706.67, "minimum": 399.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 550.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 550.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 399.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 637.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 637.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1955", "type": "HCPCS" } ], "description": "Inj levocarnitine per 1 gm", "standard_charges": [ { "billing_class": "facility", "maximum": 69.27, "minimum": 43.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 59.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 59.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 43.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1956", "type": "HCPCS" } ], "description": "Levofloxacin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5.12, "minimum": 3.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1960", "type": "HCPCS" } ], "description": "Levorphanol tartrate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 7.89, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1961", "type": "HCPCS" } ], "description": "Inj, lenacapavir, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 59.57, "minimum": 22.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 51.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 37.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1980", "type": "HCPCS" } ], "description": "Hyoscyamine sulfate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 126.36, "minimum": 24.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 126.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 126.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1990", "type": "HCPCS" } ], "description": "Chlordiazepoxide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 54.34, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2004", "type": "HCPCS" } ], "description": "Inj, lidocaine w epinephrine", "standard_charges": [ { "billing_class": "facility", "maximum": 0.08, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2010", "type": "HCPCS" } ], "description": "Lincomycin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 18.24, "minimum": 11.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.75 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2020", "type": "HCPCS" } ], "description": "Linezolid injection", "standard_charges": [ { "billing_class": "facility", "maximum": 8.08, "minimum": 5.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2021", "type": "HCPCS" } ], "description": "Inj, linezolid (hospira)", "standard_charges": [ { "billing_class": "facility", "maximum": 22.41, "minimum": 14.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2060", "type": "HCPCS" } ], "description": "Lorazepam injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.66, "minimum": 2.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2062", "type": "HCPCS" } ], "description": "Loxapine for inhalation 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 48.78, "minimum": 15.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 35.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2150", "type": "HCPCS" } ], "description": "Mannitol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 6.88, "minimum": 4.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.94 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2170", "type": "HCPCS" } ], "description": "Mecasermin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 457.64, "minimum": 344.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 344.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 344.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 457.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 457.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2175", "type": "HCPCS" } ], "description": "Meperidine hydrochl /100 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 18.86, "minimum": 11.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 16.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2182", "type": "HCPCS" } ], "description": "Injection, mepolizumab, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 83.17, "minimum": 31.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 52.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2183", "type": "HCPCS" } ], "description": "Inj meropenem (wg crit care)", "standard_charges": [ { "billing_class": "facility", "maximum": 4.47, "minimum": 2.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2184", "type": "HCPCS" } ], "description": "Inj, meropenem (b. braun)", "standard_charges": [ { "billing_class": "facility", "maximum": 5.61, "minimum": 3.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2185", "type": "HCPCS" } ], "description": "Meropenem", "standard_charges": [ { "billing_class": "facility", "maximum": 1.06, "minimum": 0.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2186", "type": "HCPCS" } ], "description": "Inj., meropenem, vaborbactam", "standard_charges": [ { "billing_class": "facility", "maximum": 5.69, "minimum": 2.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2210", "type": "HCPCS" } ], "description": "Methylergonovin maleate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 59.13, "minimum": 37.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 51.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 37.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2212", "type": "HCPCS" } ], "description": "Methylnaltrexone injection", "standard_charges": [ { "billing_class": "facility", "maximum": 4.88, "minimum": 3.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2246", "type": "HCPCS" } ], "description": "Inj, micafungin (baxter)", "standard_charges": [ { "billing_class": "facility", "maximum": 2.52, "minimum": 1.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86148", "type": "HCPCS" } ], "description": "Anti-phospholipid antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 60.26, "minimum": 16.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86152", "type": "HCPCS" } ], "description": "Cell enumeration & id", "standard_charges": [ { "billing_class": "facility", "maximum": 940.43, "minimum": 250.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 250.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 940.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 940.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86155", "type": "HCPCS" } ], "description": "Chemotaxis assay", "standard_charges": [ { "billing_class": "facility", "maximum": 59.96, "minimum": 15.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86156", "type": "HCPCS" } ], "description": "Cold agglutinin screen", "standard_charges": [ { "billing_class": "facility", "maximum": 30.26, "minimum": 8.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86157", "type": "HCPCS" } ], "description": "Cold agglutinin titer", "standard_charges": [ { "billing_class": "facility", "maximum": 30.23, "minimum": 8.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86160", "type": "HCPCS" } ], "description": "Complement antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 45.0, "minimum": 12.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86161", "type": "HCPCS" } ], "description": "Complement/function activity", "standard_charges": [ { "billing_class": "facility", "maximum": 45.0, "minimum": 12.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86162", "type": "HCPCS" } ], "description": "Complement total (ch50)", "standard_charges": [ { "billing_class": "facility", "maximum": 76.2, "minimum": 20.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86171", "type": "HCPCS" } ], "description": "Complement fixation each", "standard_charges": [ { "billing_class": "facility", "maximum": 37.54, "minimum": 10.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86200", "type": "HCPCS" } ], "description": "Ccp antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.56, "minimum": 12.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86215", "type": "HCPCS" } ], "description": "Deoxyribonuclease antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86225", "type": "HCPCS" } ], "description": "Dna antibody native", "standard_charges": [ { "billing_class": "facility", "maximum": 51.53, "minimum": 13.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86226", "type": "HCPCS" } ], "description": "Dna antibody single strand", "standard_charges": [ { "billing_class": "facility", "maximum": 45.41, "minimum": 12.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86231", "type": "HCPCS" } ], "description": "Ema each ig class", "standard_charges": [ { "billing_class": "facility", "maximum": 45.34, "minimum": 12.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86235", "type": "HCPCS" } ], "description": "Nuclear antigen antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 67.24, "minimum": 17.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86255", "type": "HCPCS" } ], "description": "Fluorescent antibody screen", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86256", "type": "HCPCS" } ], "description": "Fluorescent antibody titer", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86258", "type": "HCPCS" } ], "description": "Dgp antibody each ig class", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86277", "type": "HCPCS" } ], "description": "Growth hormone antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 59.03, "minimum": 15.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86280", "type": "HCPCS" } ], "description": "Hemagglutination inhibition", "standard_charges": [ { "billing_class": "facility", "maximum": 30.71, "minimum": 8.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86294", "type": "HCPCS" } ], "description": "Immunoassay tumor qual", "standard_charges": [ { "billing_class": "facility", "maximum": 95.89, "minimum": 25.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86300", "type": "HCPCS" } ], "description": "Immunoassay tumor ca 15-3", "standard_charges": [ { "billing_class": "facility", "maximum": 78.04, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86301", "type": "HCPCS" } ], "description": "Immunoassay tumor ca 19-9", "standard_charges": [ { "billing_class": "facility", "maximum": 78.04, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86304", "type": "HCPCS" } ], "description": "Immunoassay tumor ca 125", "standard_charges": [ { "billing_class": "facility", "maximum": 78.04, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86305", "type": "HCPCS" } ], "description": "Human epididymis protein 4", "standard_charges": [ { "billing_class": "facility", "maximum": 78.04, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86308", "type": "HCPCS" } ], "description": "Heterophile antibody screen", "standard_charges": [ { "billing_class": "facility", "maximum": 19.43, "minimum": 5.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86309", "type": "HCPCS" } ], "description": "Heterophile antibody titer", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86310", "type": "HCPCS" } ], "description": "Heterophile antibody absrbj", "standard_charges": [ { "billing_class": "facility", "maximum": 27.64, "minimum": 7.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86316", "type": "HCPCS" } ], "description": "Immunoassay tumor other", "standard_charges": [ { "billing_class": "facility", "maximum": 78.04, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86317", "type": "HCPCS" } ], "description": "Immunoassay infectious agent", "standard_charges": [ { "billing_class": "facility", "maximum": 56.21, "minimum": 14.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86318", "type": "HCPCS" } ], "description": "Immunoassay infectious agent", "standard_charges": [ { "billing_class": "facility", "maximum": 67.84, "minimum": 18.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86320", "type": "HCPCS" } ], "description": "Serum immunoelectrophoresis", "standard_charges": [ { "billing_class": "facility", "maximum": 112.2, "minimum": 29.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86325", "type": "HCPCS" } ], "description": "Other immunoelectrophoresis", "standard_charges": [ { "billing_class": "facility", "maximum": 86.74, "minimum": 23.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86327", "type": "HCPCS" } ], "description": "Immunoelectrophoresis assay", "standard_charges": [ { "billing_class": "facility", "maximum": 112.2, "minimum": 112.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86328", "type": "HCPCS" } ], "description": "Ia nfct ab sarscov2 covid19", "standard_charges": [ { "billing_class": "facility", "maximum": 169.8, "minimum": 45.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 169.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 169.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86329", "type": "HCPCS" } ], "description": "Immunodiffusion nes", "standard_charges": [ { "billing_class": "facility", "maximum": 52.69, "minimum": 14.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86331", "type": "HCPCS" } ], "description": "Immunodiffusion ouchterlony", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86332", "type": "HCPCS" } ], "description": "Immune complex assay", "standard_charges": [ { "billing_class": "facility", "maximum": 91.39, "minimum": 24.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 91.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 91.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86334", "type": "HCPCS" } ], "description": "Immunofix e-phoresis serum", "standard_charges": [ { "billing_class": "facility", "maximum": 83.78, "minimum": 22.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86335", "type": "HCPCS" } ], "description": "Immunfix e-phorsis/urine/csf", "standard_charges": [ { "billing_class": "facility", "maximum": 110.06, "minimum": 29.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 110.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86336", "type": "HCPCS" } ], "description": "Inhibin A", "standard_charges": [ { "billing_class": "facility", "maximum": 58.46, "minimum": 15.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86337", "type": "HCPCS" } ], "description": "Insulin antibodies", "standard_charges": [ { "billing_class": "facility", "maximum": 80.29, "minimum": 21.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 80.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86340", "type": "HCPCS" } ], "description": "Intrinsic factor antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 56.55, "minimum": 15.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86341", "type": "HCPCS" } ], "description": "Islet cell antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 88.39, "minimum": 23.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 88.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86343", "type": "HCPCS" } ], "description": "Leukocyte histamine release", "standard_charges": [ { "billing_class": "facility", "maximum": 46.73, "minimum": 12.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86344", "type": "HCPCS" } ], "description": "Leukocyte phagocytosis", "standard_charges": [ { "billing_class": "facility", "maximum": 38.96, "minimum": 10.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86352", "type": "HCPCS" } ], "description": "Cell function assay w/stim", "standard_charges": [ { "billing_class": "facility", "maximum": 509.48, "minimum": 135.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 135.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 509.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 509.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86353", "type": "HCPCS" } ], "description": "Lymphocyte transformation", "standard_charges": [ { "billing_class": "facility", "maximum": 183.86, "minimum": 49.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 49.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 183.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 183.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86355", "type": "HCPCS" } ], "description": "B cells total count", "standard_charges": [ { "billing_class": "facility", "maximum": 141.49, "minimum": 37.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 141.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 141.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86356", "type": "HCPCS" } ], "description": "Mononuclear cell antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 100.43, "minimum": 26.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86357", "type": "HCPCS" } ], "description": "Nk cells total count", "standard_charges": [ { "billing_class": "facility", "maximum": 141.49, "minimum": 37.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 141.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 141.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86359", "type": "HCPCS" } ], "description": "T cells total count", "standard_charges": [ { "billing_class": "facility", "maximum": 141.49, "minimum": 37.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 141.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 141.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86360", "type": "HCPCS" } ], "description": "T cell absolute count/ratio", "standard_charges": [ { "billing_class": "facility", "maximum": 176.18, "minimum": 46.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 176.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 176.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86361", "type": "HCPCS" } ], "description": "T cell absolute count", "standard_charges": [ { "billing_class": "facility", "maximum": 100.43, "minimum": 26.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86362", "type": "HCPCS" } ], "description": "Mog-igg1 antb cba each", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86363", "type": "HCPCS" } ], "description": "Mog-igg1 antb flo cytmtry ea", "standard_charges": [ { "billing_class": "facility", "maximum": 141.49, "minimum": 37.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 141.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 141.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86364", "type": "HCPCS" } ], "description": "Tiss trnsgltmnase ea ig clas", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86366", "type": "HCPCS" } ], "description": "Muscle-specific kinase antb", "standard_charges": [ { "billing_class": "facility", "maximum": 69.0, "minimum": 18.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86367", "type": "HCPCS" } ], "description": "Stem cells total count", "standard_charges": [ { "billing_class": "facility", "maximum": 291.68, "minimum": 77.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 291.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 291.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86376", "type": "HCPCS" } ], "description": "Microsomal antibody each", "standard_charges": [ { "billing_class": "facility", "maximum": 54.56, "minimum": 14.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2247", "type": "HCPCS" } ], "description": "Inj, micafungin (par pharm)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.84, "minimum": 0.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2248", "type": "HCPCS" } ], "description": "Micafungin sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.76, "minimum": 0.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2249", "type": "HCPCS" } ], "description": "Inj, remimazolam, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 6.83, "minimum": 5.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2250", "type": "HCPCS" } ], "description": "Inj midazolam hydrochloride", "standard_charges": [ { "billing_class": "facility", "maximum": 0.35, "minimum": 0.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2251", "type": "HCPCS" } ], "description": "Inj midazolam (wg crit care)", "standard_charges": [ { "billing_class": "facility", "maximum": 0.46, "minimum": 0.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.4 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2252", "type": "HCPCS" } ], "description": "Inj midazolam in 0.8% nacl", "standard_charges": [ { "billing_class": "facility", "maximum": 0.22, "minimum": 0.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2260", "type": "HCPCS" } ], "description": "Inj milrinone lactate / 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.55, "minimum": 2.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2265", "type": "HCPCS" } ], "description": "Minocycline hydrochloride", "standard_charges": [ { "billing_class": "facility", "maximum": 7.02, "minimum": 2.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2267", "type": "HCPCS" } ], "description": "Inj, mirikizumab-mrkz, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 123.01, "minimum": 43.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 106.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 106.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 77.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 123.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 123.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2270", "type": "HCPCS" } ], "description": "Morphine sulfate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 12.41, "minimum": 7.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.72 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2272", "type": "HCPCS" } ], "description": "Inj, morphine (fresenius)", "standard_charges": [ { "billing_class": "facility", "maximum": 11.0, "minimum": 6.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2274", "type": "HCPCS" } ], "description": "In morphine preservativ free", "standard_charges": [ { "billing_class": "facility", "maximum": 31.3, "minimum": 19.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 27.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 19.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2277", "type": "HCPCS" } ], "description": "Inj, motixafortide, 0.25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 68.35, "minimum": 25.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 59.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 59.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 42.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2278", "type": "HCPCS" } ], "description": "Ziconotide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 26.5, "minimum": 10.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 16.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2280", "type": "HCPCS" } ], "description": "Inj, moxifloxacin 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 23.44, "minimum": 14.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.24 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2281", "type": "HCPCS" } ], "description": "Inj moxifloxacin (fres kabi)", "standard_charges": [ { "billing_class": "facility", "maximum": 16.72, "minimum": 10.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 14.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2300", "type": "HCPCS" } ], "description": "Inj nalbuphine hydrochloride", "standard_charges": [ { "billing_class": "facility", "maximum": 9.3, "minimum": 5.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2305", "type": "HCPCS" } ], "description": "Inj, nitroglycerin, 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.82, "minimum": 2.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2310", "type": "HCPCS" } ], "description": "Inj naloxone hydrochloride", "standard_charges": [ { "billing_class": "facility", "maximum": 23.58, "minimum": 14.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2311", "type": "HCPCS" } ], "description": "Inj, naloxone hcl (zimhi)", "standard_charges": [ { "billing_class": "facility", "maximum": 4.07, "minimum": 2.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.51 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2315", "type": "HCPCS" } ], "description": "Naltrexone, depot form", "standard_charges": [ { "billing_class": "facility", "maximum": 11.17, "minimum": 4.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.64 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2320", "type": "HCPCS" } ], "description": "Nandrolone decanoate 50 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 10.51, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2323", "type": "HCPCS" } ], "description": "Natalizumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 64.71, "minimum": 24.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 55.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 55.88 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 40.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2325", "type": "HCPCS" } ], "description": "Nesiritide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 78.89, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2326", "type": "HCPCS" } ], "description": "Inj, nusinersen, 0.1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3379.34, "minimum": 1280.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1280.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2769.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2769.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3379.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3379.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2327", "type": "HCPCS" } ], "description": "Inj risankizumab-rzaa 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 40.87, "minimum": 14.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 35.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 25.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2329", "type": "HCPCS" } ], "description": "Inj ublituximab-xiiy, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 187.07, "minimum": 70.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 161.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 161.53 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 117.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 187.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 187.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2350", "type": "HCPCS" } ], "description": "Injection, ocrelizumab, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 159.27, "minimum": 59.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 59.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 137.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 137.52 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 99.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 159.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 159.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2353", "type": "HCPCS" } ], "description": "Octreotide injection, depot", "standard_charges": [ { "billing_class": "facility", "maximum": 591.78, "minimum": 203.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 203.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 510.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 510.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 371.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 591.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 591.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2354", "type": "HCPCS" } ], "description": "Octreotide inj, non-depot", "standard_charges": [ { "billing_class": "facility", "maximum": 2.2, "minimum": 1.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2355", "type": "HCPCS" } ], "description": "Oprelvekin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 648.67, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 648.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 648.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2356", "type": "HCPCS" } ], "description": "Inj tezepelumab-ekko, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 49.21, "minimum": 18.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 42.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 30.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2357", "type": "HCPCS" } ], "description": "Omalizumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 102.33, "minimum": 44.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 88.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 88.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 64.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2358", "type": "HCPCS" } ], "description": "Olanzapine long-acting inj", "standard_charges": [ { "billing_class": "facility", "maximum": 7.91, "minimum": 4.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2359", "type": "HCPCS" } ], "description": "Inj. olanzapine, 0.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.03, "minimum": 1.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2360", "type": "HCPCS" } ], "description": "Orphenadrine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 37.91, "minimum": 23.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 32.74 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 23.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2371", "type": "HCPCS" } ], "description": "Inj phenylephrine hcl 20 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2372", "type": "HCPCS" } ], "description": "Inj, biorphen, 20 micrograms", "standard_charges": [ { "billing_class": "facility", "maximum": 0.46, "minimum": 0.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.4 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2373", "type": "HCPCS" } ], "description": "Inj, immphentiv, 20 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.38, "minimum": 0.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2401", "type": "HCPCS" } ], "description": "Chloroprocaine hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.08, "minimum": 0.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2402", "type": "HCPCS" } ], "description": "Chloroprocaine (clorotekal)", "standard_charges": [ { "billing_class": "facility", "maximum": 1.0, "minimum": 0.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2403", "type": "HCPCS" } ], "description": "Chloroprocaine opht gel, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.65, "minimum": 0.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2404", "type": "HCPCS" } ], "description": "Inj, nicardipine 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.22, "minimum": 0.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2405", "type": "HCPCS" } ], "description": "Ondansetron hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.24, "minimum": 0.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2406", "type": "HCPCS" } ], "description": "Injection, oritavancin 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 117.4, "minimum": 42.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 101.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 101.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 73.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 117.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2407", "type": "HCPCS" } ], "description": "Injection, oritavancin", "standard_charges": [ { "billing_class": "facility", "maximum": 77.32, "minimum": 28.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 66.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 66.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 48.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2410", "type": "HCPCS" } ], "description": "Oxymorphone hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 6.12, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2425", "type": "HCPCS" } ], "description": "Palifermin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 92.11, "minimum": 35.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 79.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 79.54 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 57.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2426", "type": "HCPCS" } ], "description": "Paliperidone palmitate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 39.92, "minimum": 15.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 34.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 25.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2427", "type": "HCPCS" } ], "description": "Inj, invega hafyera/trinza", "standard_charges": [ { "billing_class": "facility", "maximum": 34.2, "minimum": 13.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 29.53 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 21.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2430", "type": "HCPCS" } ], "description": "Pamidronate disodium /30 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 34.09, "minimum": 21.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 29.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 21.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2440", "type": "HCPCS" } ], "description": "Papaverin hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 124.5, "minimum": 87.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 87.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 87.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 124.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 124.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2468", "type": "HCPCS" } ], "description": "Inj, palonosetron (avyxa)", "standard_charges": [ { "billing_class": "facility", "maximum": 161.9, "minimum": 58.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 135.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 135.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 161.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 161.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2469", "type": "HCPCS" } ], "description": "Palonosetron hcl", "standard_charges": [ { "billing_class": "facility", "maximum": 1.6, "minimum": 1.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.38 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2470", "type": "HCPCS" } ], "description": "Inj pantoprazole sodium 40mg", "standard_charges": [ { "billing_class": "facility", "maximum": 26.5, "minimum": 10.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2471", "type": "HCPCS" } ], "description": "Inj pantoprazole(hikma) 40mg", "standard_charges": [ { "billing_class": "facility", "maximum": 21.14, "minimum": 15.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2501", "type": "HCPCS" } ], "description": "Paricalcitol", "standard_charges": [ { "billing_class": "facility", "maximum": 2.44, "minimum": 1.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2502", "type": "HCPCS" } ], "description": "Inj, pasireotide long acting", "standard_charges": [ { "billing_class": "facility", "maximum": 1487.28, "minimum": 572.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 572.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1487.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1487.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1445.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1445.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2503", "type": "HCPCS" } ], "description": "Pegaptanib sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2459.7, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2459.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2459.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2504", "type": "HCPCS" } ], "description": "Pegademase bovine, 25 iu", "standard_charges": [ { "billing_class": "facility", "maximum": 419.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 419.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 419.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2506", "type": "HCPCS" } ], "description": "Inj pegfilgrast ex bio 0.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 89.34, "minimum": 33.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 46.75 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 33.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2507", "type": "HCPCS" } ], "description": "Pegloticase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 9620.64, "minimum": 3660.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3660.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8307.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8307.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6035.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9620.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9620.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2508", "type": "HCPCS" } ], "description": "Pegunigalsidase alfa-iwxj", "standard_charges": [ { "billing_class": "facility", "maximum": 614.6, "minimum": 228.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 530.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 530.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 385.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 614.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 614.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2510", "type": "HCPCS" } ], "description": "Penicillin g procaine inj", "standard_charges": [ { "billing_class": "facility", "maximum": 127.88, "minimum": 107.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 107.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 107.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2513", "type": "HCPCS" } ], "description": "Pentastarch 10% solution", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2515", "type": "HCPCS" } ], "description": "Pentobarbital sodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 182.98, "minimum": 27.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 123.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 123.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 182.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 182.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2540", "type": "HCPCS" } ], "description": "Penicillin g potassium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 2.03, "minimum": 1.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2543", "type": "HCPCS" } ], "description": "Piperacillin/tazobactam", "standard_charges": [ { "billing_class": "facility", "maximum": 3.09, "minimum": 1.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.67 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2545", "type": "HCPCS" } ], "description": "Pentamidine non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 215.15, "minimum": 134.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 185.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 185.77 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 134.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 215.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 215.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2547", "type": "HCPCS" } ], "description": "Injection, peramivir", "standard_charges": [ { "billing_class": "facility", "maximum": 4.55, "minimum": 1.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2550", "type": "HCPCS" } ], "description": "Promethazine hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 9.67, "minimum": 6.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.35 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2560", "type": "HCPCS" } ], "description": "Phenobarbital sodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 83.36, "minimum": 52.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.98 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 52.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2561", "type": "HCPCS" } ], "description": "Inj, sezaby, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.11, "minimum": 1.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2562", "type": "HCPCS" } ], "description": "Plerixafor injection", "standard_charges": [ { "billing_class": "facility", "maximum": 100.49, "minimum": 25.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 86.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 86.77 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 63.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2590", "type": "HCPCS" } ], "description": "Oxytocin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5.45, "minimum": 3.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2597", "type": "HCPCS" } ], "description": "Inj desmopressin acetate", "standard_charges": [ { "billing_class": "facility", "maximum": 13.41, "minimum": 8.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2598", "type": "HCPCS" } ], "description": "Inj, vasopressin, 1 unit", "standard_charges": [ { "billing_class": "facility", "maximum": 4.42, "minimum": 2.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2599", "type": "HCPCS" } ], "description": "Inj vasopressin (am reg) 1 u", "standard_charges": [ { "billing_class": "facility", "maximum": 3.25, "minimum": 2.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2601", "type": "HCPCS" } ], "description": "Inj, vasopressin (baxter)", "standard_charges": [ { "billing_class": "facility", "maximum": 9.84, "minimum": 2.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2675", "type": "HCPCS" } ], "description": "Inj progesterone per 50 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 2.41, "minimum": 1.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.08 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2679", "type": "HCPCS" } ], "description": "Inj fluphenazine hcl 1.25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 20.84, "minimum": 13.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 17.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 13.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2680", "type": "HCPCS" } ], "description": "Fluphenazine decanoate 25 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 25.5, "minimum": 16.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 16.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2690", "type": "HCPCS" } ], "description": "Procainamide hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 496.01, "minimum": 294.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 294.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 428.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 428.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 311.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 496.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 496.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2700", "type": "HCPCS" } ], "description": "Oxacillin sodium injeciton", "standard_charges": [ { "billing_class": "facility", "maximum": 2.9, "minimum": 1.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2704", "type": "HCPCS" } ], "description": "Inj, propofol, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.22, "minimum": 0.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2710", "type": "HCPCS" } ], "description": "Neostigmine methylslfte inj", "standard_charges": [ { "billing_class": "facility", "maximum": 4.5, "minimum": 1.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2720", "type": "HCPCS" } ], "description": "Inj protamine sulfate/10 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 3.09, "minimum": 1.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.67 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2724", "type": "HCPCS" } ], "description": "Protein C concentrate", "standard_charges": [ { "billing_class": "facility", "maximum": 40.73, "minimum": 15.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 35.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 25.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2730", "type": "HCPCS" } ], "description": "Pralidoxime chloride inj", "standard_charges": [ { "billing_class": "facility", "maximum": 281.95, "minimum": 202.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 202.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 202.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 281.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 281.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2760", "type": "HCPCS" } ], "description": "Phentolaine mesylate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 1069.45, "minimum": 432.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 432.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 923.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 923.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 670.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1069.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1069.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2765", "type": "HCPCS" } ], "description": "Metoclopramide hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2.79, "minimum": 1.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2770", "type": "HCPCS" } ], "description": "Quinupristin/dalfopristin", "standard_charges": [ { "billing_class": "facility", "maximum": 1090.46, "minimum": 11.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1090.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1090.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2777", "type": "HCPCS" } ], "description": "Inj, faricimab-svoa, 0.1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 95.53, "minimum": 33.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 82.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 82.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 59.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2778", "type": "HCPCS" } ], "description": "Ranibizumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 335.99, "minimum": 86.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 290.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 290.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 210.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 335.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 335.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2779", "type": "HCPCS" } ], "description": "Inj, susvimo 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 218.05, "minimum": 78.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 188.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 188.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 136.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 218.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 218.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2781", "type": "HCPCS" } ], "description": "Inj, pegcetacoplan, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 396.66, "minimum": 139.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 139.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 342.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 342.51 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 248.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 396.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 396.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86381", "type": "HCPCS" } ], "description": "Mitochondrial antibody each", "standard_charges": [ { "billing_class": "facility", "maximum": 95.44, "minimum": 25.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86382", "type": "HCPCS" } ], "description": "Neutralization test viral", "standard_charges": [ { "billing_class": "facility", "maximum": 63.41, "minimum": 16.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86384", "type": "HCPCS" } ], "description": "Nitroblue tetrazolium dye", "standard_charges": [ { "billing_class": "facility", "maximum": 51.04, "minimum": 13.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86386", "type": "HCPCS" } ], "description": "Nuclear matrix protein 22", "standard_charges": [ { "billing_class": "facility", "maximum": 81.68, "minimum": 21.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86403", "type": "HCPCS" } ], "description": "Particle agglut antbdy scrn", "standard_charges": [ { "billing_class": "facility", "maximum": 43.28, "minimum": 11.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86406", "type": "HCPCS" } ], "description": "Particle agglut antbdy titr", "standard_charges": [ { "billing_class": "facility", "maximum": 39.9, "minimum": 10.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86408", "type": "HCPCS" } ], "description": "Neutrlzg antb sarscov2 scr", "standard_charges": [ { "billing_class": "facility", "maximum": 157.99, "minimum": 42.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 157.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 157.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86409", "type": "HCPCS" } ], "description": "Neutrlzg antb sarscov2 titer", "standard_charges": [ { "billing_class": "facility", "maximum": 395.21, "minimum": 79.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 395.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 395.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86413", "type": "HCPCS" } ], "description": "Sars-cov-2 antb quantitative", "standard_charges": [ { "billing_class": "facility", "maximum": 157.58, "minimum": 51.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 157.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 157.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86430", "type": "HCPCS" } ], "description": "Rheumatoid factor test qual", "standard_charges": [ { "billing_class": "facility", "maximum": 23.03, "minimum": 6.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86431", "type": "HCPCS" } ], "description": "Rheumatoid factor quant", "standard_charges": [ { "billing_class": "facility", "maximum": 21.26, "minimum": 5.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86480", "type": "HCPCS" } ], "description": "Tb test cell immun measure", "standard_charges": [ { "billing_class": "facility", "maximum": 232.43, "minimum": 61.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 232.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 232.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86481", "type": "HCPCS" } ], "description": "Tb ag response t-cell susp", "standard_charges": [ { "billing_class": "facility", "maximum": 375.0, "minimum": 100.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 375.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 375.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86485", "type": "HCPCS" } ], "description": "Skin test candida", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86486", "type": "HCPCS" } ], "description": "Skin test nos antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86490", "type": "HCPCS" } ], "description": "Coccidioidomycosis skin test", "standard_charges": [ { "billing_class": "facility", "maximum": 215.55, "minimum": 215.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 215.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 215.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86510", "type": "HCPCS" } ], "description": "Histoplasmosis skin test", "standard_charges": [ { "billing_class": "facility", "maximum": 215.55, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 215.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 215.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86580", "type": "HCPCS" } ], "description": "TB intradermal test", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86590", "type": "HCPCS" } ], "description": "Streptokinase antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 47.48, "minimum": 12.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86592", "type": "HCPCS" } ], "description": "Syphilis test non-trep qual", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86593", "type": "HCPCS" } ], "description": "Syphilis test non-trep quant", "standard_charges": [ { "billing_class": "facility", "maximum": 16.5, "minimum": 4.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86596", "type": "HCPCS" } ], "description": "Voltage-gtd ca chnl antb ea", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86602", "type": "HCPCS" } ], "description": "Antinomyces antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 38.18, "minimum": 10.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86603", "type": "HCPCS" } ], "description": "Adenovirus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.26, "minimum": 12.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86606", "type": "HCPCS" } ], "description": "Aspergillus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 56.44, "minimum": 15.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86609", "type": "HCPCS" } ], "description": "Bacterium antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.3, "minimum": 12.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86611", "type": "HCPCS" } ], "description": "Bartonella Antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 38.18, "minimum": 10.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86612", "type": "HCPCS" } ], "description": "Blastomyces antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.38, "minimum": 12.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86615", "type": "HCPCS" } ], "description": "Bordetella antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86617", "type": "HCPCS" } ], "description": "Lyme disease antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 58.09, "minimum": 15.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86618", "type": "HCPCS" } ], "description": "Lyme disease antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 63.86, "minimum": 17.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86619", "type": "HCPCS" } ], "description": "Borrelia antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 50.18, "minimum": 13.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86622", "type": "HCPCS" } ], "description": "Brucella antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 33.49, "minimum": 8.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86625", "type": "HCPCS" } ], "description": "Campylobacter antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.2, "minimum": 13.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86628", "type": "HCPCS" } ], "description": "Candida antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 45.04, "minimum": 12.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86631", "type": "HCPCS" } ], "description": "Chlamydia antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 44.33, "minimum": 11.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86632", "type": "HCPCS" } ], "description": "Chlamydia igm antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 47.55, "minimum": 12.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86635", "type": "HCPCS" } ], "description": "Coccidioides antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 43.01, "minimum": 11.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86638", "type": "HCPCS" } ], "description": "Q fever antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 45.45, "minimum": 12.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86641", "type": "HCPCS" } ], "description": "Cryptococcus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 54.04, "minimum": 14.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86644", "type": "HCPCS" } ], "description": "CMV antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 53.96, "minimum": 14.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86645", "type": "HCPCS" } ], "description": "Cmv antibody igm", "standard_charges": [ { "billing_class": "facility", "maximum": 63.19, "minimum": 16.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86648", "type": "HCPCS" } ], "description": "Diphtheria antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 57.04, "minimum": 15.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86651", "type": "HCPCS" } ], "description": "Encephalitis californ antbdy", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86652", "type": "HCPCS" } ], "description": "Encephaltis east eqne anbdy", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86653", "type": "HCPCS" } ], "description": "Encephaltis st louis antbody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86654", "type": "HCPCS" } ], "description": "Encephaltis west eqne antbdy", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86658", "type": "HCPCS" } ], "description": "Enterovirus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.86, "minimum": 13.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86663", "type": "HCPCS" } ], "description": "Epstein-barr antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.2, "minimum": 13.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86664", "type": "HCPCS" } ], "description": "Epstein-barr nuclear antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 57.34, "minimum": 15.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86665", "type": "HCPCS" } ], "description": "Epstein-barr capsid vca", "standard_charges": [ { "billing_class": "facility", "maximum": 68.03, "minimum": 18.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86666", "type": "HCPCS" } ], "description": "Ehrlichia Antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 38.18, "minimum": 10.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86668", "type": "HCPCS" } ], "description": "Francisella tularensis", "standard_charges": [ { "billing_class": "facility", "maximum": 53.1, "minimum": 14.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86671", "type": "HCPCS" } ], "description": "Fungus nes antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 45.94, "minimum": 12.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86674", "type": "HCPCS" } ], "description": "Giardia lamblia antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 55.2, "minimum": 14.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86677", "type": "HCPCS" } ], "description": "Helicobacter pylori antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 63.19, "minimum": 16.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86682", "type": "HCPCS" } ], "description": "Helminth antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.79, "minimum": 13.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86684", "type": "HCPCS" } ], "description": "Hemophilus influenza antibdy", "standard_charges": [ { "billing_class": "facility", "maximum": 59.4, "minimum": 15.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86687", "type": "HCPCS" } ], "description": "Htlv-i antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 34.09, "minimum": 9.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86688", "type": "HCPCS" } ], "description": "Htlv-ii antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 52.5, "minimum": 14.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86689", "type": "HCPCS" } ], "description": "Htlv/hiv confirmj antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 72.56, "minimum": 19.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86692", "type": "HCPCS" } ], "description": "Hepatitis delta agent antbdy", "standard_charges": [ { "billing_class": "facility", "maximum": 64.35, "minimum": 17.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86694", "type": "HCPCS" } ], "description": "Herpes simplex nes antbdy", "standard_charges": [ { "billing_class": "facility", "maximum": 53.96, "minimum": 14.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86695", "type": "HCPCS" } ], "description": "Herpes simplex type 1 test", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86696", "type": "HCPCS" } ], "description": "Herpes simplex type 2 test", "standard_charges": [ { "billing_class": "facility", "maximum": 72.56, "minimum": 19.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86698", "type": "HCPCS" } ], "description": "Histoplasma antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 51.71, "minimum": 13.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86701", "type": "HCPCS" } ], "description": "Hiv-1antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 33.34, "minimum": 8.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86702", "type": "HCPCS" } ], "description": "Hiv-2 antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 50.7, "minimum": 13.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86703", "type": "HCPCS" } ], "description": "Hiv-1/hiv-2 1 result antbdy", "standard_charges": [ { "billing_class": "facility", "maximum": 51.41, "minimum": 13.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86704", "type": "HCPCS" } ], "description": "Hep b core antibody total", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86705", "type": "HCPCS" } ], "description": "Hep b core antibody igm", "standard_charges": [ { "billing_class": "facility", "maximum": 44.14, "minimum": 11.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86706", "type": "HCPCS" } ], "description": "Hep b surface antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 40.28, "minimum": 10.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86707", "type": "HCPCS" } ], "description": "Hepatitis be antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 43.39, "minimum": 11.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86708", "type": "HCPCS" } ], "description": "Hepatitis a antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 46.46, "minimum": 12.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86709", "type": "HCPCS" } ], "description": "Hepatitis a igm antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 42.23, "minimum": 11.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86710", "type": "HCPCS" } ], "description": "Influenza virus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 50.81, "minimum": 13.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86711", "type": "HCPCS" } ], "description": "John cunningham antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 63.34, "minimum": 16.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86713", "type": "HCPCS" } ], "description": "Legionella antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 57.38, "minimum": 15.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86717", "type": "HCPCS" } ], "description": "Leishmania antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 45.94, "minimum": 12.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86720", "type": "HCPCS" } ], "description": "Leptospira antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 60.75, "minimum": 16.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86723", "type": "HCPCS" } ], "description": "Listeria monocytogenes", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86727", "type": "HCPCS" } ], "description": "Lymph choriomeningitis ab", "standard_charges": [ { "billing_class": "facility", "maximum": 48.26, "minimum": 12.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86732", "type": "HCPCS" } ], "description": "Mucormycosis antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 56.25, "minimum": 15.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86735", "type": "HCPCS" } ], "description": "Mumps antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.94, "minimum": 13.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86738", "type": "HCPCS" } ], "description": "Mycoplasma antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.65, "minimum": 13.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86741", "type": "HCPCS" } ], "description": "Neisseria meningitidis", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86744", "type": "HCPCS" } ], "description": "Nocardia antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 59.96, "minimum": 15.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86747", "type": "HCPCS" } ], "description": "Parvovirus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 56.36, "minimum": 15.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86750", "type": "HCPCS" } ], "description": "Malaria antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86753", "type": "HCPCS" } ], "description": "Protozoa antibody nos", "standard_charges": [ { "billing_class": "facility", "maximum": 46.46, "minimum": 12.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86756", "type": "HCPCS" } ], "description": "Respiratory virus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 59.59, "minimum": 15.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86757", "type": "HCPCS" } ], "description": "Rickettsia Antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 72.56, "minimum": 19.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86759", "type": "HCPCS" } ], "description": "Rotavirus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 68.36, "minimum": 18.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86762", "type": "HCPCS" } ], "description": "Rubella antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 53.96, "minimum": 14.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86765", "type": "HCPCS" } ], "description": "Rubeola antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.3, "minimum": 12.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86768", "type": "HCPCS" } ], "description": "Salmonella antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86769", "type": "HCPCS" } ], "description": "Sars-cov-2 covid-19 antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 157.99, "minimum": 42.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 157.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 157.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86771", "type": "HCPCS" } ], "description": "Shigella antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 91.8, "minimum": 24.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 91.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 91.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86774", "type": "HCPCS" } ], "description": "Tetanus antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 55.5, "minimum": 14.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86777", "type": "HCPCS" } ], "description": "Toxoplasma antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 53.96, "minimum": 14.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86778", "type": "HCPCS" } ], "description": "Toxoplasma antibody igm", "standard_charges": [ { "billing_class": "facility", "maximum": 54.04, "minimum": 14.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86780", "type": "HCPCS" } ], "description": "Treponema pallidum", "standard_charges": [ { "billing_class": "facility", "maximum": 49.65, "minimum": 13.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86784", "type": "HCPCS" } ], "description": "Trichinella antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 47.1, "minimum": 12.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86787", "type": "HCPCS" } ], "description": "Varicella-zoster antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 48.3, "minimum": 12.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86788", "type": "HCPCS" } ], "description": "West nile virus ab igm", "standard_charges": [ { "billing_class": "facility", "maximum": 63.19, "minimum": 16.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86789", "type": "HCPCS" } ], "description": "West Nile Virus Antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 53.96, "minimum": 14.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86790", "type": "HCPCS" } ], "description": "Virus antibody nos", "standard_charges": [ { "billing_class": "facility", "maximum": 48.3, "minimum": 12.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86793", "type": "HCPCS" } ], "description": "Yersinia antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 49.46, "minimum": 13.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86794", "type": "HCPCS" } ], "description": "Zika virus igm antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 63.19, "minimum": 16.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86800", "type": "HCPCS" } ], "description": "Thyroglobulin antibody", "standard_charges": [ { "billing_class": "facility", "maximum": 59.66, "minimum": 15.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86803", "type": "HCPCS" } ], "description": "Hepatitis c ab test", "standard_charges": [ { "billing_class": "facility", "maximum": 53.51, "minimum": 14.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86804", "type": "HCPCS" } ], "description": "Hep c ab test confirm", "standard_charges": [ { "billing_class": "facility", "maximum": 58.09, "minimum": 15.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86805", "type": "HCPCS" } ], "description": "Lymphocytotoxicity assay", "standard_charges": [ { "billing_class": "facility", "maximum": 710.66, "minimum": 189.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 189.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 710.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 710.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86806", "type": "HCPCS" } ], "description": "Lymphocytotoxicity assay", "standard_charges": [ { "billing_class": "facility", "maximum": 178.46, "minimum": 47.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 178.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 178.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86807", "type": "HCPCS" } ], "description": "Cytotoxic antibody screening", "standard_charges": [ { "billing_class": "facility", "maximum": 294.94, "minimum": 78.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 294.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 294.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86808", "type": "HCPCS" } ], "description": "Cytotoxic antibody screening", "standard_charges": [ { "billing_class": "facility", "maximum": 111.3, "minimum": 29.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86812", "type": "HCPCS" } ], "description": "Hla typing a b or c", "standard_charges": [ { "billing_class": "facility", "maximum": 96.79, "minimum": 25.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 96.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 96.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86813", "type": "HCPCS" } ], "description": "Hla typing a b or c", "standard_charges": [ { "billing_class": "facility", "maximum": 217.5, "minimum": 58.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 217.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 217.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86816", "type": "HCPCS" } ], "description": "Hla typing dr/dq", "standard_charges": [ { "billing_class": "facility", "maximum": 113.14, "minimum": 30.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 113.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86817", "type": "HCPCS" } ], "description": "Hla typing dr/dq", "standard_charges": [ { "billing_class": "facility", "maximum": 398.03, "minimum": 106.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 106.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 398.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 398.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2782", "type": "HCPCS" } ], "description": "Inj avacincaptad pegol 0.1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 294.58, "minimum": 105.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 105.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 254.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 254.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 184.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 294.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 294.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2783", "type": "HCPCS" } ], "description": "Rasburicase", "standard_charges": [ { "billing_class": "facility", "maximum": 1002.62, "minimum": 377.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 865.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 865.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 628.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1002.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1002.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2785", "type": "HCPCS" } ], "description": "Regadenoson injection", "standard_charges": [ { "billing_class": "facility", "maximum": 10.33, "minimum": 6.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.92 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2786", "type": "HCPCS" } ], "description": "Injection, reslizumab, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 27.97, "minimum": 10.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.15 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2787", "type": "HCPCS" } ], "description": "Riboflavin 5?phos opth<=3ml", "standard_charges": [ { "billing_class": "facility", "maximum": 7414.56, "minimum": 5335.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5335.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5335.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7414.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7414.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2788", "type": "HCPCS" } ], "description": "Rho d immune globulin 50 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 66.56, "minimum": 41.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 57.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 41.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2790", "type": "HCPCS" } ], "description": "Rho d immune globulin inj", "standard_charges": [ { "billing_class": "facility", "maximum": 225.91, "minimum": 141.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 195.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 195.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 141.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 225.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 225.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2791", "type": "HCPCS" } ], "description": "Rhophylac injection", "standard_charges": [ { "billing_class": "facility", "maximum": 13.25, "minimum": 8.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2792", "type": "HCPCS" } ], "description": "Rho(D) immune globulin h, sd", "standard_charges": [ { "billing_class": "facility", "maximum": 89.05, "minimum": 25.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 76.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 76.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 55.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 89.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 89.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2793", "type": "HCPCS" } ], "description": "Rilonacept injection", "standard_charges": [ { "billing_class": "facility", "maximum": 73.17, "minimum": 63.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 63.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2794", "type": "HCPCS" } ], "description": "Risperidone, long acting", "standard_charges": [ { "billing_class": "facility", "maximum": 29.78, "minimum": 10.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 25.72 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 18.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2795", "type": "HCPCS" } ], "description": "Ropivacaine HCl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.19, "minimum": 0.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2797", "type": "HCPCS" } ], "description": "Inj., rolapitant, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2798", "type": "HCPCS" } ], "description": "Inj., perseris, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 33.03, "minimum": 12.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.52 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 20.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2799", "type": "HCPCS" } ], "description": "Inj, uzedy, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 66.99, "minimum": 25.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 57.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 42.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2800", "type": "HCPCS" } ], "description": "Methocarbamol injection", "standard_charges": [ { "billing_class": "facility", "maximum": 17.8, "minimum": 11.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2801", "type": "HCPCS" } ], "description": "Inj, rykindo, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 35.31, "minimum": 13.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2805", "type": "HCPCS" } ], "description": "Sincalide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 310.0, "minimum": 194.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 267.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 267.67 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 194.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 310.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 310.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2810", "type": "HCPCS" } ], "description": "Inj theophylline per 40 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 2.85, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2820", "type": "HCPCS" } ], "description": "Sargramostim injection", "standard_charges": [ { "billing_class": "facility", "maximum": 162.65, "minimum": 50.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 140.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 140.45 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 102.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 162.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 162.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2840", "type": "HCPCS" } ], "description": "Inj sebelipase alfa 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1462.1, "minimum": 539.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 539.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1194.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1194.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1462.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1462.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2850", "type": "HCPCS" } ], "description": "Inj secretin synthetic human", "standard_charges": [ { "billing_class": "facility", "maximum": 115.36, "minimum": 40.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 92.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 92.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 115.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 115.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2860", "type": "HCPCS" } ], "description": "Injection, siltuximab", "standard_charges": [ { "billing_class": "facility", "maximum": 422.68, "minimum": 165.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 165.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 364.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 364.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 265.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 422.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 422.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2910", "type": "HCPCS" } ], "description": "Aurothioglucose injeciton", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2916", "type": "HCPCS" } ], "description": "Na ferric gluconate complex", "standard_charges": [ { "billing_class": "facility", "maximum": 5.39, "minimum": 3.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2919", "type": "HCPCS" } ], "description": "Inj, methylpred sod succ 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.73, "minimum": 0.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2941", "type": "HCPCS" } ], "description": "Somatropin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 355.24, "minimum": 132.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 355.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 355.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 132.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2993", "type": "HCPCS" } ], "description": "Reteplase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 7526.05, "minimum": 2904.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2904.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7069.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7069.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7526.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7526.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2997", "type": "HCPCS" } ], "description": "Alteplase recombinant", "standard_charges": [ { "billing_class": "facility", "maximum": 247.91, "minimum": 94.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 214.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 214.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 155.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 247.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 247.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2998", "type": "HCPCS" } ], "description": "Inj plasminogen tvmh 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 88.13, "minimum": 32.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 77.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 88.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3000", "type": "HCPCS" } ], "description": "Streptomycin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 76.58, "minimum": 48.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 66.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 66.13 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 48.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3010", "type": "HCPCS" } ], "description": "Fentanyl citrate injeciton", "standard_charges": [ { "billing_class": "facility", "maximum": 2.3, "minimum": 1.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3030", "type": "HCPCS" } ], "description": "Sumatriptan succinate / 6 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 438.83, "minimum": 114.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 114.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 114.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 438.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 438.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3031", "type": "HCPCS" } ], "description": "Inj., fremanezumab-vfrm 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 10.98, "minimum": 7.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3032", "type": "HCPCS" } ], "description": "Inj. eptinezumab-jjmr 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 52.36, "minimum": 19.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 45.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 32.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3055", "type": "HCPCS" } ], "description": "Inj talquetamab-tgvs 0.25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 189.62, "minimum": 72.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 72.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 163.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 163.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 118.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 189.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 189.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3060", "type": "HCPCS" } ], "description": "Inj, taliglucerace alfa 10 u", "standard_charges": [ { "billing_class": "facility", "maximum": 112.79, "minimum": 41.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 97.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 97.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 70.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3070", "type": "HCPCS" } ], "description": "Pentazocine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 71.87, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3090", "type": "HCPCS" } ], "description": "Inj tedizolid phosphate", "standard_charges": [ { "billing_class": "facility", "maximum": 4.91, "minimum": 1.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.24 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3095", "type": "HCPCS" } ], "description": "Telavancin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 20.05, "minimum": 7.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 17.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3101", "type": "HCPCS" } ], "description": "Tenecteplase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 440.19, "minimum": 172.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 172.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 380.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 380.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 276.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 440.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 440.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3105", "type": "HCPCS" } ], "description": "Terbutaline sulfate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 5.8, "minimum": 3.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3110", "type": "HCPCS" } ], "description": "Teriparatide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 189.65, "minimum": 117.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 117.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 117.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 189.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 189.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3111", "type": "HCPCS" } ], "description": "Inj. romosozumab-aqqg 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 31.14, "minimum": 12.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 26.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 19.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3121", "type": "HCPCS" } ], "description": "Inj testostero enanthate 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.14, "minimum": 0.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3145", "type": "HCPCS" } ], "description": "Testosterone undecanoate 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.2, "minimum": 2.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3230", "type": "HCPCS" } ], "description": "Chlorpromazine hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 82.6, "minimum": 51.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 51.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3240", "type": "HCPCS" } ], "description": "Thyrotropin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5604.04, "minimum": 2116.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2116.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4838.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4838.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3515.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5604.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5604.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3241", "type": "HCPCS" } ], "description": "Inj. teprotumumab-trbw 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 940.64, "minimum": 359.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 812.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 812.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 590.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 940.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 940.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3243", "type": "HCPCS" } ], "description": "Tigecycline injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.71, "minimum": 1.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3244", "type": "HCPCS" } ], "description": "Inj. tigecycline (accord)", "standard_charges": [ { "billing_class": "facility", "maximum": 9.16, "minimum": 5.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3245", "type": "HCPCS" } ], "description": "Inj., tildrakizumab, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 360.92, "minimum": 127.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 127.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 311.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 311.64 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 226.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 360.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 360.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3246", "type": "HCPCS" } ], "description": "Tirofiban hcl", "standard_charges": [ { "billing_class": "facility", "maximum": 9.81, "minimum": 6.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3247", "type": "HCPCS" } ], "description": "Inj secukinumab intrav 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 48.02, "minimum": 17.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 41.46 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 30.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3250", "type": "HCPCS" } ], "description": "Trimethobenzamide hcl inj", "standard_charges": [ { "billing_class": "facility", "maximum": 138.07, "minimum": 86.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 119.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 119.22 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 86.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 138.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 138.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3260", "type": "HCPCS" } ], "description": "Tobramycin sulfate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5.34, "minimum": 3.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3262", "type": "HCPCS" } ], "description": "Tocilizumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 16.18, "minimum": 5.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 13.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3263", "type": "HCPCS" } ], "description": "Inj, toripalimab-tpzi, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 106.56, "minimum": 39.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 92.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 92.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 66.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 106.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3265", "type": "HCPCS" } ], "description": "Injection torsemide 10 mg/ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3285", "type": "HCPCS" } ], "description": "Treprostinil injection", "standard_charges": [ { "billing_class": "facility", "maximum": 151.62, "minimum": 54.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 130.92 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 95.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 151.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 151.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3299", "type": "HCPCS" } ], "description": "Inj xipere 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 131.22, "minimum": 47.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 113.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 113.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 82.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3300", "type": "HCPCS" } ], "description": "Triamcinolone A inj PRS-free", "standard_charges": [ { "billing_class": "facility", "maximum": 76.75, "minimum": 24.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 55.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 55.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3301", "type": "HCPCS" } ], "description": "Triamcinolone acet inj nos", "standard_charges": [ { "billing_class": "facility", "maximum": 2.44, "minimum": 1.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3303", "type": "HCPCS" } ], "description": "Triamcinolone hexacetonl inj", "standard_charges": [ { "billing_class": "facility", "maximum": 26.42, "minimum": 19.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86821", "type": "HCPCS" } ], "description": "Lymphocyte culture mixed", "standard_charges": [ { "billing_class": "facility", "maximum": 137.1, "minimum": 36.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 137.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 137.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86825", "type": "HCPCS" } ], "description": "Hla x-math non-cytotoxic", "standard_charges": [ { "billing_class": "facility", "maximum": 410.59, "minimum": 109.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 109.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 410.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 410.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86826", "type": "HCPCS" } ], "description": "Hla x-match noncytotoxc addl", "standard_charges": [ { "billing_class": "facility", "maximum": 136.99, "minimum": 36.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 136.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 136.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86828", "type": "HCPCS" } ], "description": "Hla class i&ii antibody qual", "standard_charges": [ { "billing_class": "facility", "maximum": 240.71, "minimum": 64.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 240.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 240.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86829", "type": "HCPCS" } ], "description": "Hla class i/ii antibody qual", "standard_charges": [ { "billing_class": "facility", "maximum": 240.71, "minimum": 64.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 240.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 240.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86830", "type": "HCPCS" } ], "description": "Hla class i phenotype qual", "standard_charges": [ { "billing_class": "facility", "maximum": 358.2, "minimum": 95.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 95.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 358.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 358.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86831", "type": "HCPCS" } ], "description": "Hla class ii phenotype qual", "standard_charges": [ { "billing_class": "facility", "maximum": 307.05, "minimum": 81.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 307.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 307.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86832", "type": "HCPCS" } ], "description": "Hla class i high defin qual", "standard_charges": [ { "billing_class": "facility", "maximum": 1214.06, "minimum": 323.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 323.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1214.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1214.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86833", "type": "HCPCS" } ], "description": "Hla class ii high defin qual", "standard_charges": [ { "billing_class": "facility", "maximum": 1221.75, "minimum": 325.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 325.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1221.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1221.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86834", "type": "HCPCS" } ], "description": "Hla class i semiquant panel", "standard_charges": [ { "billing_class": "facility", "maximum": 1340.85, "minimum": 357.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 357.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1340.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1340.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86835", "type": "HCPCS" } ], "description": "Hla class ii semiquant panel", "standard_charges": [ { "billing_class": "facility", "maximum": 1211.1, "minimum": 322.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 322.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1211.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1211.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86850", "type": "HCPCS" } ], "description": "RBC antibody screen", "standard_charges": [ { "billing_class": "facility", "maximum": 50.25, "minimum": 36.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86860", "type": "HCPCS" } ], "description": "RBC antibody elution", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86870", "type": "HCPCS" } ], "description": "RBC antibody identification", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 345.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86880", "type": "HCPCS" } ], "description": "Coombs test direct", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 20.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86885", "type": "HCPCS" } ], "description": "Coombs test indirect qual", "standard_charges": [ { "billing_class": "facility", "maximum": 164.27, "minimum": 21.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86886", "type": "HCPCS" } ], "description": "Coombs test indirect titer", "standard_charges": [ { "billing_class": "facility", "maximum": 164.27, "minimum": 19.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86890", "type": "HCPCS" } ], "description": "Autologous blood process", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86891", "type": "HCPCS" } ], "description": "Autologous blood op salvage", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86900", "type": "HCPCS" } ], "description": "Blood typing serologic abo", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 11.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86901", "type": "HCPCS" } ], "description": "Blood typing serologic rh(d)", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 11.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86902", "type": "HCPCS" } ], "description": "Blood type antigen donor ea", "standard_charges": [ { "billing_class": "facility", "maximum": 345.62, "minimum": 23.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86904", "type": "HCPCS" } ], "description": "Blood typing patient serum", "standard_charges": [ { "billing_class": "facility", "maximum": 61.28, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86905", "type": "HCPCS" } ], "description": "Blood typing rbc antigens", "standard_charges": [ { "billing_class": "facility", "maximum": 345.62, "minimum": 14.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86906", "type": "HCPCS" } ], "description": "Bld typing serologic rh phnt", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 29.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86910", "type": "HCPCS" } ], "description": "Blood typing paternity test", "standard_charges": [ { "billing_class": "facility", "maximum": 94.05, "minimum": 94.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86911", "type": "HCPCS" } ], "description": "Blood typing antigen system", "standard_charges": [ { "billing_class": "facility", "maximum": 81.34, "minimum": 81.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86920", "type": "HCPCS" } ], "description": "Compatibility test spin", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86921", "type": "HCPCS" } ], "description": "Compatibility test incubate", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86922", "type": "HCPCS" } ], "description": "Compatibility test antiglob", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3304", "type": "HCPCS" } ], "description": "Inj triamcinolone ace xr 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 48.78, "minimum": 18.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 42.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 30.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3305", "type": "HCPCS" } ], "description": "Inj trimetrexate glucoronate", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3315", "type": "HCPCS" } ], "description": "Triptorelin pamoate", "standard_charges": [ { "billing_class": "facility", "maximum": 1304.3, "minimum": 474.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 474.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1126.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1126.22 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 818.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1304.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1304.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3316", "type": "HCPCS" } ], "description": "Inj., triptorelin xr 3.75 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 9517.76, "minimum": 3817.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3817.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8696.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8696.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9517.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9517.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3355", "type": "HCPCS" } ], "description": "Urofollitropin, 75 iu", "standard_charges": [ { "billing_class": "facility", "maximum": 160.4, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3357", "type": "HCPCS" } ], "description": "Ustekinumab sub cu inj, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 422.43, "minimum": 265.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 364.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 364.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 265.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 422.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 422.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3358", "type": "HCPCS" } ], "description": "Ustekinumab, iv inject, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 34.58, "minimum": 12.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 29.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 21.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3360", "type": "HCPCS" } ], "description": "Diazepam injection", "standard_charges": [ { "billing_class": "facility", "maximum": 23.17, "minimum": 14.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3364", "type": "HCPCS" } ], "description": "Urokinase 5000 IU injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3365", "type": "HCPCS" } ], "description": "Urokinase 250,000 IU inj", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3370", "type": "HCPCS" } ], "description": "Vancomycin hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5.04, "minimum": 3.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.35 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3371", "type": "HCPCS" } ], "description": "Inj, vancomycin hcl (mylan)", "standard_charges": [ { "billing_class": "facility", "maximum": 17.43, "minimum": 10.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.05 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3372", "type": "HCPCS" } ], "description": "Inj, vancomycin hcl (xellia)", "standard_charges": [ { "billing_class": "facility", "maximum": 17.29, "minimum": 10.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 14.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3380", "type": "HCPCS" } ], "description": "Injection, vedolizumab", "standard_charges": [ { "billing_class": "facility", "maximum": 58.73, "minimum": 21.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 50.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 36.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3385", "type": "HCPCS" } ], "description": "Velaglucerase alfa", "standard_charges": [ { "billing_class": "facility", "maximum": 1013.59, "minimum": 381.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 381.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 875.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 875.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 635.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1013.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1013.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3393", "type": "HCPCS" } ], "description": "Inj, betibeglogene autotemce", "standard_charges": [ { "billing_class": "facility", "maximum": 8043280.0, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2945740.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8043280.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8043280.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3394", "type": "HCPCS" } ], "description": "Inj, lovotibeglogene autotem", "standard_charges": [ { "billing_class": "facility", "maximum": 8653030.0, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3248445.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8653030.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8653030.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3396", "type": "HCPCS" } ], "description": "Verteporfin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 31.17, "minimum": 11.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 26.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 19.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3397", "type": "HCPCS" } ], "description": "Inj., vestronidase alfa-vjbk", "standard_charges": [ { "billing_class": "facility", "maximum": 857.55, "minimum": 279.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 279.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 617.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 617.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 857.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 857.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3398", "type": "HCPCS" } ], "description": "Inj luxturna 1 billion vec g", "standard_charges": [ { "billing_class": "facility", "maximum": 8599.45, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3002.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8599.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8599.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3399", "type": "HCPCS" } ], "description": "Inj onase abepar-xioi treat", "standard_charges": [ { "billing_class": "facility", "maximum": 6513373.21, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2455110.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6513373.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6513373.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3401", "type": "HCPCS" } ], "description": "Vyjuvek 5x10^9pfu/ml, 0.1 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 2755.47, "minimum": 1025.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1025.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2379.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2379.27 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1728.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2755.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2755.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3410", "type": "HCPCS" } ], "description": "Hydroxyzine hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 33.36, "minimum": 20.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 20.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3411", "type": "HCPCS" } ], "description": "Thiamine hcl 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.77, "minimum": 3.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3415", "type": "HCPCS" } ], "description": "Pyridoxine hcl 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 42.76, "minimum": 26.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 36.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 26.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3420", "type": "HCPCS" } ], "description": "Vitamin b12 injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.44, "minimum": 2.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3424", "type": "HCPCS" } ], "description": "Inj hydroxocobalamin iv 25mg", "standard_charges": [ { "billing_class": "facility", "maximum": 14.04, "minimum": 5.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3425", "type": "HCPCS" } ], "description": "Inj, hydroxocobalamin", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3430", "type": "HCPCS" } ], "description": "Vitamin k phytonadione inj", "standard_charges": [ { "billing_class": "facility", "maximum": 5.99, "minimum": 3.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3465", "type": "HCPCS" } ], "description": "Injection, voriconazole", "standard_charges": [ { "billing_class": "facility", "maximum": 2.63, "minimum": 1.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.27 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3470", "type": "HCPCS" } ], "description": "Hyaluronidase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 81.49, "minimum": 51.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 70.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 51.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3471", "type": "HCPCS" } ], "description": "Ovine, up to 999 usp units", "standard_charges": [ { "billing_class": "facility", "maximum": 1.17, "minimum": 1.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86923", "type": "HCPCS" } ], "description": "Compatibility test electric", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86927", "type": "HCPCS" } ], "description": "Plasma fresh frozen", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86930", "type": "HCPCS" } ], "description": "Frozen blood prep", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86931", "type": "HCPCS" } ], "description": "Frozen blood thaw", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86932", "type": "HCPCS" } ], "description": "Frozen blood freeze/thaw", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86940", "type": "HCPCS" } ], "description": "Hemolysins/agglutinins auto", "standard_charges": [ { "billing_class": "facility", "maximum": 32.89, "minimum": 8.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86941", "type": "HCPCS" } ], "description": "Hemolysins/agglutinins", "standard_charges": [ { "billing_class": "facility", "maximum": 45.41, "minimum": 12.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86945", "type": "HCPCS" } ], "description": "Blood product/irradiation", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86950", "type": "HCPCS" } ], "description": "Leukacyte transfusion", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86960", "type": "HCPCS" } ], "description": "Vol reduction of blood/prod", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86965", "type": "HCPCS" } ], "description": "Pooling blood platelets", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86970", "type": "HCPCS" } ], "description": "Rbc pretx incubatj w/chemicl", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86971", "type": "HCPCS" } ], "description": "Rbc pretx incubatj w/enzymes", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86972", "type": "HCPCS" } ], "description": "Rbc pretx incubatj w/density", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86975", "type": "HCPCS" } ], "description": "Rbc serum pretx incubj drugs", "standard_charges": [ { "billing_class": "facility", "maximum": 1415.89, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1415.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1415.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86976", "type": "HCPCS" } ], "description": "Rbc serum pretx id dilution", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86977", "type": "HCPCS" } ], "description": "Rbc serum pretx incubj/inhib", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86978", "type": "HCPCS" } ], "description": "Rbc pretreatment serum", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86985", "type": "HCPCS" } ], "description": "Split blood or products", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86999", "type": "HCPCS" } ], "description": "Transfusion procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87003", "type": "HCPCS" } ], "description": "Small animal inoculation", "standard_charges": [ { "billing_class": "facility", "maximum": 63.15, "minimum": 16.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87015", "type": "HCPCS" } ], "description": "Specimen infect agnt concntj", "standard_charges": [ { "billing_class": "facility", "maximum": 25.05, "minimum": 6.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87040", "type": "HCPCS" } ], "description": "Blood culture for bacteria", "standard_charges": [ { "billing_class": "facility", "maximum": 38.7, "minimum": 10.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87045", "type": "HCPCS" } ], "description": "Feces culture aerobic bact", "standard_charges": [ { "billing_class": "facility", "maximum": 35.4, "minimum": 9.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87046", "type": "HCPCS" } ], "description": "Stool cultr aerobic bact ea", "standard_charges": [ { "billing_class": "facility", "maximum": 35.4, "minimum": 9.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87070", "type": "HCPCS" } ], "description": "Culture othr specimn aerobic", "standard_charges": [ { "billing_class": "facility", "maximum": 32.33, "minimum": 8.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87071", "type": "HCPCS" } ], "description": "Culture aerobic quant other", "standard_charges": [ { "billing_class": "facility", "maximum": 37.09, "minimum": 9.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87073", "type": "HCPCS" } ], "description": "Culture Bacteria Anaerobic", "standard_charges": [ { "billing_class": "facility", "maximum": 36.23, "minimum": 9.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87075", "type": "HCPCS" } ], "description": "Cultr bacteria except blood", "standard_charges": [ { "billing_class": "facility", "maximum": 35.51, "minimum": 9.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87076", "type": "HCPCS" } ], "description": "Culture anaerobe ident each", "standard_charges": [ { "billing_class": "facility", "maximum": 30.3, "minimum": 8.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3472", "type": "HCPCS" } ], "description": "Ovine, 1000 USP units", "standard_charges": [ { "billing_class": "facility", "maximum": 288.4, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 288.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 288.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3473", "type": "HCPCS" } ], "description": "Hyaluronidase recombinant", "standard_charges": [ { "billing_class": "facility", "maximum": 1.0, "minimum": 0.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3475", "type": "HCPCS" } ], "description": "Inj magnesium sulfate", "standard_charges": [ { "billing_class": "facility", "maximum": 1.33, "minimum": 0.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.15 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3480", "type": "HCPCS" } ], "description": "Inj potassium chloride", "standard_charges": [ { "billing_class": "facility", "maximum": 0.27, "minimum": 0.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.23 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3485", "type": "HCPCS" } ], "description": "Zidovudine", "standard_charges": [ { "billing_class": "facility", "maximum": 4.09, "minimum": 1.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.53 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3486", "type": "HCPCS" } ], "description": "Ziprasidone mesylate", "standard_charges": [ { "billing_class": "facility", "maximum": 19.48, "minimum": 12.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 16.82 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3489", "type": "HCPCS" } ], "description": "Zoledronic acid 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 15.18, "minimum": 9.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 13.1 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3520", "type": "HCPCS" } ], "description": "Edetate disodium per 150 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7030", "type": "HCPCS" } ], "description": "Normal saline solution infus", "standard_charges": [ { "billing_class": "facility", "maximum": 6.78, "minimum": 4.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7040", "type": "HCPCS" } ], "description": "Normal saline solution infus", "standard_charges": [ { "billing_class": "facility", "maximum": 3.39, "minimum": 2.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7042", "type": "HCPCS" } ], "description": "5% dextrose/normal saline", "standard_charges": [ { "billing_class": "facility", "maximum": 3.2, "minimum": 2.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7050", "type": "HCPCS" } ], "description": "Normal saline solution infus", "standard_charges": [ { "billing_class": "facility", "maximum": 1.71, "minimum": 1.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7060", "type": "HCPCS" } ], "description": "5% dextrose/water", "standard_charges": [ { "billing_class": "facility", "maximum": 4.88, "minimum": 3.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7070", "type": "HCPCS" } ], "description": "D5w infusion", "standard_charges": [ { "billing_class": "facility", "maximum": 9.76, "minimum": 6.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7100", "type": "HCPCS" } ], "description": "Dextran 40 infusion", "standard_charges": [ { "billing_class": "facility", "maximum": 139.65, "minimum": 91.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 91.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 91.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 139.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 139.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7110", "type": "HCPCS" } ], "description": "Dextran 75 infusion", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7120", "type": "HCPCS" } ], "description": "Ringers lactate infusion", "standard_charges": [ { "billing_class": "facility", "maximum": 6.53, "minimum": 4.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.64 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7121", "type": "HCPCS" } ], "description": "5% dextrose in lac ringers", "standard_charges": [ { "billing_class": "facility", "maximum": 18.67, "minimum": 16.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7131", "type": "HCPCS" } ], "description": "Hypertonic saline sol", "standard_charges": [ { "billing_class": "facility", "maximum": 0.35, "minimum": 0.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7165", "type": "HCPCS" } ], "description": "Inj, human-lans, per i.u", "standard_charges": [ { "billing_class": "facility", "maximum": 7.37, "minimum": 1.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7168", "type": "HCPCS" } ], "description": "Prothrombin complex kcentra", "standard_charges": [ { "billing_class": "facility", "maximum": 6.97, "minimum": 2.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7169", "type": "HCPCS" } ], "description": "Inj andexxa, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 357.18, "minimum": 131.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 131.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 292.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 292.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 357.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 357.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7170", "type": "HCPCS" } ], "description": "Inj., emicizumab-kxwh 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 140.97, "minimum": 56.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 121.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 121.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 88.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 140.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7171", "type": "HCPCS" } ], "description": "Inj, adzynma, 10 iu", "standard_charges": [ { "billing_class": "facility", "maximum": 93.68, "minimum": 35.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 80.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 80.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 58.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7175", "type": "HCPCS" } ], "description": "Inj, factor x, (human), 1iu", "standard_charges": [ { "billing_class": "facility", "maximum": 25.83, "minimum": 9.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 16.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7177", "type": "HCPCS" } ], "description": "Inj., fibryga, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.01, "minimum": 1.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7178", "type": "HCPCS" } ], "description": "Human fibrinogen conc inj", "standard_charges": [ { "billing_class": "facility", "maximum": 4.01, "minimum": 1.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.46 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7179", "type": "HCPCS" } ], "description": "Vonvendi inj 1 iu vwf:rco", "standard_charges": [ { "billing_class": "facility", "maximum": 5.01, "minimum": 1.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7180", "type": "HCPCS" } ], "description": "Factor XIII anti-hem factor", "standard_charges": [ { "billing_class": "facility", "maximum": 28.37, "minimum": 10.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7181", "type": "HCPCS" } ], "description": "Factor xiii recomb a-subunit", "standard_charges": [ { "billing_class": "facility", "maximum": 46.53, "minimum": 18.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 40.18 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 29.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7182", "type": "HCPCS" } ], "description": "Factor viii recomb novoeight", "standard_charges": [ { "billing_class": "facility", "maximum": 3.88, "minimum": 1.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.35 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7183", "type": "HCPCS" } ], "description": "Wilate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.47, "minimum": 1.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87077", "type": "HCPCS" } ], "description": "Culture Aerobic Identify", "standard_charges": [ { "billing_class": "facility", "maximum": 30.3, "minimum": 8.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87081", "type": "HCPCS" } ], "description": "Culture screen only", "standard_charges": [ { "billing_class": "facility", "maximum": 24.86, "minimum": 6.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87084", "type": "HCPCS" } ], "description": "Culture of specimen by kit", "standard_charges": [ { "billing_class": "facility", "maximum": 101.51, "minimum": 27.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87086", "type": "HCPCS" } ], "description": "Urine culture/colony count", "standard_charges": [ { "billing_class": "facility", "maximum": 30.26, "minimum": 8.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87088", "type": "HCPCS" } ], "description": "Urine bacteria culture", "standard_charges": [ { "billing_class": "facility", "maximum": 30.34, "minimum": 8.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87101", "type": "HCPCS" } ], "description": "Skin fungi culture", "standard_charges": [ { "billing_class": "facility", "maximum": 28.91, "minimum": 7.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87102", "type": "HCPCS" } ], "description": "Fungus isolation culture", "standard_charges": [ { "billing_class": "facility", "maximum": 31.54, "minimum": 8.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87103", "type": "HCPCS" } ], "description": "Blood fungus culture", "standard_charges": [ { "billing_class": "facility", "maximum": 76.73, "minimum": 20.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87106", "type": "HCPCS" } ], "description": "Fungi identification yeast", "standard_charges": [ { "billing_class": "facility", "maximum": 38.7, "minimum": 10.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87107", "type": "HCPCS" } ], "description": "Fungi identification mold", "standard_charges": [ { "billing_class": "facility", "maximum": 38.7, "minimum": 10.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87109", "type": "HCPCS" } ], "description": "Mycoplasma", "standard_charges": [ { "billing_class": "facility", "maximum": 57.71, "minimum": 15.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87110", "type": "HCPCS" } ], "description": "Chlamydia culture", "standard_charges": [ { "billing_class": "facility", "maximum": 73.5, "minimum": 19.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87116", "type": "HCPCS" } ], "description": "Mycobacteria culture", "standard_charges": [ { "billing_class": "facility", "maximum": 40.5, "minimum": 10.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87118", "type": "HCPCS" } ], "description": "Mycobacteric identification", "standard_charges": [ { "billing_class": "facility", "maximum": 54.79, "minimum": 14.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87140", "type": "HCPCS" } ], "description": "Culture type immunofluoresc", "standard_charges": [ { "billing_class": "facility", "maximum": 20.89, "minimum": 5.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87143", "type": "HCPCS" } ], "description": "Culture typing glc/hplc", "standard_charges": [ { "billing_class": "facility", "maximum": 46.95, "minimum": 12.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87147", "type": "HCPCS" } ], "description": "Culture type immunologic", "standard_charges": [ { "billing_class": "facility", "maximum": 19.43, "minimum": 5.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87149", "type": "HCPCS" } ], "description": "Dna/rna direct probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87150", "type": "HCPCS" } ], "description": "Dna/rna amplified probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87152", "type": "HCPCS" } ], "description": "Culture Type Pulse Field Gel", "standard_charges": [ { "billing_class": "facility", "maximum": 29.03, "minimum": 7.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87153", "type": "HCPCS" } ], "description": "Dna/rna sequencing", "standard_charges": [ { "billing_class": "facility", "maximum": 432.6, "minimum": 115.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 115.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 432.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 432.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87154", "type": "HCPCS" } ], "description": "Cul typ id bld pthgn 6+ trgt", "standard_charges": [ { "billing_class": "facility", "maximum": 817.73, "minimum": 218.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 817.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 817.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87158", "type": "HCPCS" } ], "description": "Culture typing added method", "standard_charges": [ { "billing_class": "facility", "maximum": 29.03, "minimum": 7.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87164", "type": "HCPCS" } ], "description": "Dark field examination", "standard_charges": [ { "billing_class": "facility", "maximum": 40.28, "minimum": 10.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87166", "type": "HCPCS" } ], "description": "Dark field examination", "standard_charges": [ { "billing_class": "facility", "maximum": 42.38, "minimum": 11.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87168", "type": "HCPCS" } ], "description": "Macroscopic Exam Arthropod", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87169", "type": "HCPCS" } ], "description": "Macroscopic exam parasite", "standard_charges": [ { "billing_class": "facility", "maximum": 16.16, "minimum": 4.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87172", "type": "HCPCS" } ], "description": "Pinworm Exam", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87176", "type": "HCPCS" } ], "description": "Tissue homogenization cultr", "standard_charges": [ { "billing_class": "facility", "maximum": 22.05, "minimum": 5.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87177", "type": "HCPCS" } ], "description": "Ova and parasites smears", "standard_charges": [ { "billing_class": "facility", "maximum": 33.38, "minimum": 8.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87181", "type": "HCPCS" } ], "description": "Microbe susceptible diffuse", "standard_charges": [ { "billing_class": "facility", "maximum": 17.81, "minimum": 4.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87184", "type": "HCPCS" } ], "description": "Microbe susceptible disk", "standard_charges": [ { "billing_class": "facility", "maximum": 28.05, "minimum": 7.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87185", "type": "HCPCS" } ], "description": "Microbe susceptible enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 17.81, "minimum": 4.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87186", "type": "HCPCS" } ], "description": "Microbe susceptible mic", "standard_charges": [ { "billing_class": "facility", "maximum": 32.44, "minimum": 8.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87187", "type": "HCPCS" } ], "description": "Microbe susceptible mlc", "standard_charges": [ { "billing_class": "facility", "maximum": 150.64, "minimum": 40.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 150.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 150.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87188", "type": "HCPCS" } ], "description": "Microbe suscept macrobroth", "standard_charges": [ { "billing_class": "facility", "maximum": 24.9, "minimum": 6.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87190", "type": "HCPCS" } ], "description": "Microbe suscept mycobacteri", "standard_charges": [ { "billing_class": "facility", "maximum": 27.41, "minimum": 7.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87197", "type": "HCPCS" } ], "description": "Bactericidal level serum", "standard_charges": [ { "billing_class": "facility", "maximum": 56.33, "minimum": 15.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87205", "type": "HCPCS" } ], "description": "Smear gram stain", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87206", "type": "HCPCS" } ], "description": "Smear fluorescent/acid stai", "standard_charges": [ { "billing_class": "facility", "maximum": 20.21, "minimum": 5.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87207", "type": "HCPCS" } ], "description": "Smear special stain", "standard_charges": [ { "billing_class": "facility", "maximum": 22.46, "minimum": 5.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87209", "type": "HCPCS" } ], "description": "Smear complex stain", "standard_charges": [ { "billing_class": "facility", "maximum": 67.43, "minimum": 17.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87210", "type": "HCPCS" } ], "description": "Smear wet mount saline/ink", "standard_charges": [ { "billing_class": "facility", "maximum": 21.83, "minimum": 5.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87220", "type": "HCPCS" } ], "description": "Tissue exam for fungi", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87230", "type": "HCPCS" } ], "description": "Assay toxin or antitoxin", "standard_charges": [ { "billing_class": "facility", "maximum": 74.03, "minimum": 19.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 74.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87250", "type": "HCPCS" } ], "description": "Virus inoculate eggs/animal", "standard_charges": [ { "billing_class": "facility", "maximum": 73.35, "minimum": 19.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87252", "type": "HCPCS" } ], "description": "Virus inoculation tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 97.76, "minimum": 26.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 97.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 97.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87253", "type": "HCPCS" } ], "description": "Virus inoculate tissue addl", "standard_charges": [ { "billing_class": "facility", "maximum": 75.75, "minimum": 20.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87254", "type": "HCPCS" } ], "description": "Virus inoculation shell via", "standard_charges": [ { "billing_class": "facility", "maximum": 73.35, "minimum": 19.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87255", "type": "HCPCS" } ], "description": "Genet virus isolate hsv", "standard_charges": [ { "billing_class": "facility", "maximum": 126.98, "minimum": 33.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 126.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 126.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87260", "type": "HCPCS" } ], "description": "Adenovirus ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 54.11, "minimum": 14.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87265", "type": "HCPCS" } ], "description": "Pertussis ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87267", "type": "HCPCS" } ], "description": "Enterovirus antibody dfa", "standard_charges": [ { "billing_class": "facility", "maximum": 50.33, "minimum": 13.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87269", "type": "HCPCS" } ], "description": "Giardia ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 51.04, "minimum": 13.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87270", "type": "HCPCS" } ], "description": "Chlamydia trachomatis ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87271", "type": "HCPCS" } ], "description": "Cytomegalovirus dfa", "standard_charges": [ { "billing_class": "facility", "maximum": 50.33, "minimum": 13.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87272", "type": "HCPCS" } ], "description": "Cryptosporidium ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87273", "type": "HCPCS" } ], "description": "Herpes simplex 2 ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87274", "type": "HCPCS" } ], "description": "Herpes simplex 1 ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87275", "type": "HCPCS" } ], "description": "Influenza b ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 45.94, "minimum": 12.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7185", "type": "HCPCS" } ], "description": "Xyntha inj", "standard_charges": [ { "billing_class": "facility", "maximum": 4.07, "minimum": 1.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.51 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7186", "type": "HCPCS" } ], "description": "Antihemophilic viii/vwf comp", "standard_charges": [ { "billing_class": "facility", "maximum": 3.25, "minimum": 1.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7187", "type": "HCPCS" } ], "description": "Humate-P, inj", "standard_charges": [ { "billing_class": "facility", "maximum": 3.93, "minimum": 1.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7188", "type": "HCPCS" } ], "description": "Factor viii recomb obizur", "standard_charges": [ { "billing_class": "facility", "maximum": 8.75, "minimum": 3.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7189", "type": "HCPCS" } ], "description": "Factor viia", "standard_charges": [ { "billing_class": "facility", "maximum": 6.91, "minimum": 2.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7190", "type": "HCPCS" } ], "description": "Factor viii", "standard_charges": [ { "billing_class": "facility", "maximum": 3.04, "minimum": 1.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.62 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7192", "type": "HCPCS" } ], "description": "Factor viii recombinant nos", "standard_charges": [ { "billing_class": "facility", "maximum": 4.17, "minimum": 1.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7193", "type": "HCPCS" } ], "description": "Factor ix non-recombinant", "standard_charges": [ { "billing_class": "facility", "maximum": 3.63, "minimum": 1.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.14 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7194", "type": "HCPCS" } ], "description": "Factor ix complex", "standard_charges": [ { "billing_class": "facility", "maximum": 4.5, "minimum": 1.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.88 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7195", "type": "HCPCS" } ], "description": "Factor ix recombinant nos", "standard_charges": [ { "billing_class": "facility", "maximum": 4.99, "minimum": 1.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.31 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7196", "type": "HCPCS" } ], "description": "Antithrombin recombinant", "standard_charges": [ { "billing_class": "facility", "maximum": 328.77, "minimum": 328.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 328.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 328.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7197", "type": "HCPCS" } ], "description": "Antithrombin iii injection", "standard_charges": [ { "billing_class": "facility", "maximum": 10.73, "minimum": 4.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.27 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7198", "type": "HCPCS" } ], "description": "Anti-inhibitor", "standard_charges": [ { "billing_class": "facility", "maximum": 6.4, "minimum": 2.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.52 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7200", "type": "HCPCS" } ], "description": "Factor ix recombinan rixubis", "standard_charges": [ { "billing_class": "facility", "maximum": 4.47, "minimum": 1.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7201", "type": "HCPCS" } ], "description": "Factor ix alprolix recomb", "standard_charges": [ { "billing_class": "facility", "maximum": 9.7, "minimum": 3.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.38 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7202", "type": "HCPCS" } ], "description": "Factor ix idelvion inj", "standard_charges": [ { "billing_class": "facility", "maximum": 14.12, "minimum": 5.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7203", "type": "HCPCS" } ], "description": "Factor ix recomb gly rebinyn", "standard_charges": [ { "billing_class": "facility", "maximum": 11.9, "minimum": 4.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.27 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7204", "type": "HCPCS" } ], "description": "Inj recombin esperoct per iu", "standard_charges": [ { "billing_class": "facility", "maximum": 5.93, "minimum": 2.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7205", "type": "HCPCS" } ], "description": "Factor viii fc fusion recomb", "standard_charges": [ { "billing_class": "facility", "maximum": 6.34, "minimum": 2.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.48 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7207", "type": "HCPCS" } ], "description": "Factor viii pegylated recomb", "standard_charges": [ { "billing_class": "facility", "maximum": 5.69, "minimum": 2.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7208", "type": "HCPCS" } ], "description": "Inj. jivi 1 iu", "standard_charges": [ { "billing_class": "facility", "maximum": 6.64, "minimum": 2.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7209", "type": "HCPCS" } ], "description": "Factor viii nuwiq recomb 1iu", "standard_charges": [ { "billing_class": "facility", "maximum": 3.36, "minimum": 1.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7210", "type": "HCPCS" } ], "description": "Inj, afstyla, 1 i.u.", "standard_charges": [ { "billing_class": "facility", "maximum": 4.12, "minimum": 1.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7211", "type": "HCPCS" } ], "description": "Inj, kovaltry, 1 i.u.", "standard_charges": [ { "billing_class": "facility", "maximum": 4.01, "minimum": 1.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.46 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7212", "type": "HCPCS" } ], "description": "Factor viia recomb sevenfact", "standard_charges": [ { "billing_class": "facility", "maximum": 6.37, "minimum": 2.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7213", "type": "HCPCS" } ], "description": "Inj, ixinity, 1 i.u.", "standard_charges": [ { "billing_class": "facility", "maximum": 5.96, "minimum": 1.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.15 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7214", "type": "HCPCS" } ], "description": "Altuviiio per factor viii iu", "standard_charges": [ { "billing_class": "facility", "maximum": 12.57, "minimum": 4.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7294", "type": "HCPCS" } ], "description": "Seg acet and eth estr yearly", "standard_charges": [ { "billing_class": "facility", "maximum": 7871.63, "minimum": 5664.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5664.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5664.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7871.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7871.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7295", "type": "HCPCS" } ], "description": "Eth estr and eton monthly", "standard_charges": [ { "billing_class": "facility", "maximum": 506.63, "minimum": 287.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 287.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 287.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 506.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 506.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7296", "type": "HCPCS" } ], "description": "Kyleena, 19.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3761.89, "minimum": 2842.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2842.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2842.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3761.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3761.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7297", "type": "HCPCS" } ], "description": "Liletta, 52 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2885.69, "minimum": 2076.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2076.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2076.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2885.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2885.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7298", "type": "HCPCS" } ], "description": "Mirena, 52 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3761.89, "minimum": 2842.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2842.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2842.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3761.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3761.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87276", "type": "HCPCS" } ], "description": "Influenza a ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 60.26, "minimum": 16.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87278", "type": "HCPCS" } ], "description": "Legion pneumophilia ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 58.5, "minimum": 15.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87279", "type": "HCPCS" } ], "description": "Parainfluenza ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 61.61, "minimum": 16.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87280", "type": "HCPCS" } ], "description": "Respiratory syncytial ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 50.33, "minimum": 13.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87281", "type": "HCPCS" } ], "description": "Pneumocystis carinii ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87283", "type": "HCPCS" } ], "description": "Rubeola ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 228.0, "minimum": 60.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 228.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 228.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87285", "type": "HCPCS" } ], "description": "Treponema pallidum ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 45.68, "minimum": 12.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87290", "type": "HCPCS" } ], "description": "Varicella zoster ag if", "standard_charges": [ { "billing_class": "facility", "maximum": 50.33, "minimum": 13.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87299", "type": "HCPCS" } ], "description": "Antibody detection nos if", "standard_charges": [ { "billing_class": "facility", "maximum": 60.38, "minimum": 16.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87300", "type": "HCPCS" } ], "description": "Ag detection polyval if", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87301", "type": "HCPCS" } ], "description": "Adenovirus ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87305", "type": "HCPCS" } ], "description": "Aspergillus ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87320", "type": "HCPCS" } ], "description": "Chylmd trach ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 56.25, "minimum": 15.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87324", "type": "HCPCS" } ], "description": "Clostridium ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87327", "type": "HCPCS" } ], "description": "Cryptococcus neoform ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 50.33, "minimum": 13.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87328", "type": "HCPCS" } ], "description": "Cryptosporidium ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 51.83, "minimum": 13.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87329", "type": "HCPCS" } ], "description": "Giardia ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87332", "type": "HCPCS" } ], "description": "Cytomegalovirus ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87335", "type": "HCPCS" } ], "description": "E coli 0157 ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 47.48, "minimum": 12.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87336", "type": "HCPCS" } ], "description": "Entamoeb hist dispr ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 60.0, "minimum": 16.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87337", "type": "HCPCS" } ], "description": "Entamoeb hist group ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87338", "type": "HCPCS" } ], "description": "Hpylori stool ia", "standard_charges": [ { "billing_class": "facility", "maximum": 53.93, "minimum": 14.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87339", "type": "HCPCS" } ], "description": "H pylori ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 60.0, "minimum": 16.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87340", "type": "HCPCS" } ], "description": "Hepatitis b surface ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 38.74, "minimum": 10.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87341", "type": "HCPCS" } ], "description": "Hepatitis b surface ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 38.74, "minimum": 10.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87350", "type": "HCPCS" } ], "description": "Hepatitis be ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87380", "type": "HCPCS" } ], "description": "Hepatitis delta ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 68.85, "minimum": 18.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87385", "type": "HCPCS" } ], "description": "Histoplasma capsul ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87389", "type": "HCPCS" } ], "description": "Hiv-1 ag w/hiv-1 & hiv-2 ab", "standard_charges": [ { "billing_class": "facility", "maximum": 90.3, "minimum": 24.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87390", "type": "HCPCS" } ], "description": "Hiv-1 ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 90.23, "minimum": 24.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7300", "type": "HCPCS" } ], "description": "Intraut copper contraceptive", "standard_charges": [ { "billing_class": "facility", "maximum": 3701.86, "minimum": 2665.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2665.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2665.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3701.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3701.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7301", "type": "HCPCS" } ], "description": "Skyla, 13.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3132.38, "minimum": 2366.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2366.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2366.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3132.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3132.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7307", "type": "HCPCS" } ], "description": "Etonogestrel implant system", "standard_charges": [ { "billing_class": "facility", "maximum": 3949.99, "minimum": 2842.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2842.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2842.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3949.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3949.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7308", "type": "HCPCS" } ], "description": "Aminolevulinic acid hcl top", "standard_charges": [ { "billing_class": "facility", "maximum": 1071.15, "minimum": 392.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 392.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 924.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 924.91 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 671.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1071.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1071.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7309", "type": "HCPCS" } ], "description": "Methyl aminolevulinate, top", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7310", "type": "HCPCS" } ], "description": "Ganciclovir long act implant", "standard_charges": [ { "billing_class": "facility", "maximum": 11123.93, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11123.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11123.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7311", "type": "HCPCS" } ], "description": "Fluocinolone acetonide implt", "standard_charges": [ { "billing_class": "facility", "maximum": 903.05, "minimum": 340.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 340.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 779.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 779.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 566.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 903.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 903.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7312", "type": "HCPCS" } ], "description": "Dexamethasone intra implant", "standard_charges": [ { "billing_class": "facility", "maximum": 557.07, "minimum": 204.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 204.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 481.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 481.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 349.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 557.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 557.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7313", "type": "HCPCS" } ], "description": "Fluocinol acet intravit imp", "standard_charges": [ { "billing_class": "facility", "maximum": 1337.87, "minimum": 498.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 498.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1155.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1155.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 839.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1337.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1337.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7314", "type": "HCPCS" } ], "description": "Inj., yutiq, 0.01 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1425.16, "minimum": 529.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 529.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1230.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1230.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 894.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1425.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1425.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7315", "type": "HCPCS" } ], "description": "Ophthalmic mitomycin", "standard_charges": [ { "billing_class": "facility", "maximum": 1006.2, "minimum": 1006.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1006.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1006.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7316", "type": "HCPCS" } ], "description": "Inj, ocriplasmin, 0.125 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7318", "type": "HCPCS" } ], "description": "Inj, durolane 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 18.16, "minimum": 6.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7320", "type": "HCPCS" } ], "description": "Genvisc 850, inj, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 16.72, "minimum": 5.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 14.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7321", "type": "HCPCS" } ], "description": "Hyalgan/supartz inj per dose", "standard_charges": [ { "billing_class": "facility", "maximum": 197.91, "minimum": 124.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 170.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 170.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 124.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 197.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 197.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7322", "type": "HCPCS" } ], "description": "Hymovis injection 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 47.21, "minimum": 17.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 40.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 29.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7323", "type": "HCPCS" } ], "description": "Euflexxa inj per dose", "standard_charges": [ { "billing_class": "facility", "maximum": 327.04, "minimum": 112.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 112.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 282.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 282.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 205.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 327.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 327.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7324", "type": "HCPCS" } ], "description": "Orthovisc inj per dose", "standard_charges": [ { "billing_class": "facility", "maximum": 249.7, "minimum": 114.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 215.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 215.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 156.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 249.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 249.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7325", "type": "HCPCS" } ], "description": "Synvisc or Synvisc-One", "standard_charges": [ { "billing_class": "facility", "maximum": 24.82, "minimum": 7.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 21.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 15.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7326", "type": "HCPCS" } ], "description": "Gel-one", "standard_charges": [ { "billing_class": "facility", "maximum": 1426.49, "minimum": 529.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 529.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1231.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1231.73 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 894.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1426.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1426.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7327", "type": "HCPCS" } ], "description": "Monovisc inj per dose", "standard_charges": [ { "billing_class": "facility", "maximum": 1530.2, "minimum": 636.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 636.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1321.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1321.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 959.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1530.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1530.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7328", "type": "HCPCS" } ], "description": "Gel-syn injection 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.52, "minimum": 0.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.31 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7329", "type": "HCPCS" } ], "description": "Inj, trivisc 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 16.53, "minimum": 4.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 14.27 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7330", "type": "HCPCS" } ], "description": "Cultured chondrocytes implnt", "standard_charges": [ { "billing_class": "facility", "maximum": 197282.58, "minimum": 141956.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 141956.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 141956.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 197282.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 197282.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7331", "type": "HCPCS" } ], "description": "Synojoynt, inj., 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 24.12, "minimum": 15.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 15.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7332", "type": "HCPCS" } ], "description": "Inj., triluron, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 27.34, "minimum": 10.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 23.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7336", "type": "HCPCS" } ], "description": "Capsaicin 8% patch", "standard_charges": [ { "billing_class": "facility", "maximum": 9.02, "minimum": 3.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.79 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7340", "type": "HCPCS" } ], "description": "Carbidopa levodopa ent 100ml", "standard_charges": [ { "billing_class": "facility", "maximum": 639.42, "minimum": 243.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 243.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 552.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 552.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 401.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 639.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 639.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7342", "type": "HCPCS" } ], "description": "Ciprofloxacin otic susp 6 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 92.09, "minimum": 66.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 66.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 66.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7345", "type": "HCPCS" } ], "description": "Aminolevulinic acid, 10% gel", "standard_charges": [ { "billing_class": "facility", "maximum": 4.66, "minimum": 1.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7351", "type": "HCPCS" } ], "description": "Inj bimatoprost itc imp 1mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 568.8, "minimum": 213.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 213.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 491.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 491.14 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 356.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 568.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 568.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7353", "type": "HCPCS" } ], "description": "Anacaulase-bcdb 8.8% gel 1 g", "standard_charges": [ { "billing_class": "facility", "maximum": 154.44, "minimum": 58.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 134.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 134.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 154.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 154.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7354", "type": "HCPCS" } ], "description": "Cantharidin top, applicator", "standard_charges": [ { "billing_class": "facility", "maximum": 1928.84, "minimum": 654.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 654.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1665.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1665.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1209.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1928.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1928.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7355", "type": "HCPCS" } ], "description": "Inj travoprost intra impl", "standard_charges": [ { "billing_class": "facility", "maximum": 534.3, "minimum": 195.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 195.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 435.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 435.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7402", "type": "HCPCS" } ], "description": "Mometasone sinus sinuva", "standard_charges": [ { "billing_class": "facility", "maximum": 30.76, "minimum": 11.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 26.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 19.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7500", "type": "HCPCS" } ], "description": "Azathioprine oral 50mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.22, "minimum": 2.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.78 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7501", "type": "HCPCS" } ], "description": "Azathioprine parenteral", "standard_charges": [ { "billing_class": "facility", "maximum": 620.51, "minimum": 254.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 254.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 585.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 585.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 620.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 620.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7502", "type": "HCPCS" } ], "description": "Cyclosporine oral 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.96, "minimum": 3.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.15 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7503", "type": "HCPCS" } ], "description": "Tacrol envarsus ex rel oral", "standard_charges": [ { "billing_class": "facility", "maximum": 4.88, "minimum": 3.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7504", "type": "HCPCS" } ], "description": "Lymphocyte immune globulin", "standard_charges": [ { "billing_class": "facility", "maximum": 11804.03, "minimum": 5135.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5135.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10192.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10192.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7404.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11804.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11804.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7505", "type": "HCPCS" } ], "description": "Monoclonal antibodies", "standard_charges": [ { "billing_class": "facility", "maximum": 2353.64, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2353.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2353.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7507", "type": "HCPCS" } ], "description": "Tacrolimus imme rel oral 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.49, "minimum": 0.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7508", "type": "HCPCS" } ], "description": "Tacrol astagraf ex rel oral", "standard_charges": [ { "billing_class": "facility", "maximum": 1.54, "minimum": 0.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7509", "type": "HCPCS" } ], "description": "Methylprednisolone oral", "standard_charges": [ { "billing_class": "facility", "maximum": 0.68, "minimum": 0.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.59 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7510", "type": "HCPCS" } ], "description": "Prednisolone oral per 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.54, "minimum": 0.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7511", "type": "HCPCS" } ], "description": "Antithymocyte globuln rabbit", "standard_charges": [ { "billing_class": "facility", "maximum": 2575.2, "minimum": 999.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 999.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2223.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2223.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1615.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2575.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2575.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7512", "type": "HCPCS" } ], "description": "Prednisone ir or dr oral 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7513", "type": "HCPCS" } ], "description": "Daclizumab, parenteral", "standard_charges": [ { "billing_class": "facility", "maximum": 1015.98, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1015.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1015.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7515", "type": "HCPCS" } ], "description": "Cyclosporine oral 25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.25, "minimum": 1.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.94 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7516", "type": "HCPCS" } ], "description": "Cyclosporin parenteral 250mg", "standard_charges": [ { "billing_class": "facility", "maximum": 193.39, "minimum": 121.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 166.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 166.98 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 121.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 193.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 193.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7517", "type": "HCPCS" } ], "description": "Mycophenolate mofetil oral", "standard_charges": [ { "billing_class": "facility", "maximum": 0.41, "minimum": 0.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7518", "type": "HCPCS" } ], "description": "Mycophenolic acid", "standard_charges": [ { "billing_class": "facility", "maximum": 1.3, "minimum": 0.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7519", "type": "HCPCS" } ], "description": "Inj. mycophenolate mofetil", "standard_charges": [ { "billing_class": "facility", "maximum": 1.11, "minimum": 0.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.96 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7520", "type": "HCPCS" } ], "description": "Sirolimus, oral", "standard_charges": [ { "billing_class": "facility", "maximum": 2.87, "minimum": 1.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.48 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7525", "type": "HCPCS" } ], "description": "Tacrolimus injection", "standard_charges": [ { "billing_class": "facility", "maximum": 690.16, "minimum": 263.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 263.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 595.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 595.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 432.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 690.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 690.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7527", "type": "HCPCS" } ], "description": "Oral everolimus", "standard_charges": [ { "billing_class": "facility", "maximum": 6.29, "minimum": 3.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7605", "type": "HCPCS" } ], "description": "Arformoterol non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 2.2, "minimum": 1.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7606", "type": "HCPCS" } ], "description": "Formoterol fumarate, inh", "standard_charges": [ { "billing_class": "facility", "maximum": 5.12, "minimum": 3.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7608", "type": "HCPCS" } ], "description": "Acetylcysteine non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 22.09, "minimum": 13.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 13.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7609", "type": "HCPCS" } ], "description": "Albuterol comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 1.76, "minimum": 1.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7611", "type": "HCPCS" } ], "description": "Albuterol non-comp con", "standard_charges": [ { "billing_class": "facility", "maximum": 0.43, "minimum": 0.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7612", "type": "HCPCS" } ], "description": "Levalbuterol non-comp con", "standard_charges": [ { "billing_class": "facility", "maximum": 0.79, "minimum": 0.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7613", "type": "HCPCS" } ], "description": "Albuterol non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 0.19, "minimum": 0.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7614", "type": "HCPCS" } ], "description": "Levalbuterol non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 0.24, "minimum": 0.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87391", "type": "HCPCS" } ], "description": "Hiv-2 ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 82.13, "minimum": 21.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87400", "type": "HCPCS" } ], "description": "Influenza a/b ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 52.99, "minimum": 14.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87420", "type": "HCPCS" } ], "description": "Resp syncytial ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 52.16, "minimum": 13.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87425", "type": "HCPCS" } ], "description": "Rotavirus ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87426", "type": "HCPCS" } ], "description": "Coronavirus ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 132.49, "minimum": 35.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 132.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87427", "type": "HCPCS" } ], "description": "Shiga-like toxin ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87428", "type": "HCPCS" } ], "description": "Sarscov & inf vir a&b ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 263.59, "minimum": 70.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 263.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 263.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87430", "type": "HCPCS" } ], "description": "Strep a ag ia", "standard_charges": [ { "billing_class": "facility", "maximum": 63.04, "minimum": 16.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87449", "type": "HCPCS" } ], "description": "Ag detect nos ia mult", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87451", "type": "HCPCS" } ], "description": "Ag detect polyval ia mult", "standard_charges": [ { "billing_class": "facility", "maximum": 39.41, "minimum": 10.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87467", "type": "HCPCS" } ], "description": "Hepatitis b surface ag quan", "standard_charges": [ { "billing_class": "facility", "maximum": 56.44, "minimum": 25.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87468", "type": "HCPCS" } ], "description": "Anaplsma phgcytophlm amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87469", "type": "HCPCS" } ], "description": "Babesia microti amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87471", "type": "HCPCS" } ], "description": "Bartonella dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87472", "type": "HCPCS" } ], "description": "Bartonella dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87475", "type": "HCPCS" } ], "description": "Lyme dis dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87476", "type": "HCPCS" } ], "description": "Lyme dis dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87478", "type": "HCPCS" } ], "description": "Borrelia miyamotoi amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87480", "type": "HCPCS" } ], "description": "Candida dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87481", "type": "HCPCS" } ], "description": "Candida dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87482", "type": "HCPCS" } ], "description": "Candida dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 209.03, "minimum": 55.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 209.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 209.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87483", "type": "HCPCS" } ], "description": "Cns dna amp probe type 12-25", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87484", "type": "HCPCS" } ], "description": "Ehrlicha chaffeensis amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87485", "type": "HCPCS" } ], "description": "Chylmd pneum dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87486", "type": "HCPCS" } ], "description": "Chylmd pneum dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87487", "type": "HCPCS" } ], "description": "Chylmd pneum dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87490", "type": "HCPCS" } ], "description": "Chylmd trach dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 85.31, "minimum": 22.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 85.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87491", "type": "HCPCS" } ], "description": "Chylmd trach dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87492", "type": "HCPCS" } ], "description": "Chylmd trach dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 200.51, "minimum": 53.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 200.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 200.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87493", "type": "HCPCS" } ], "description": "C diff amplified probe", "standard_charges": [ { "billing_class": "facility", "maximum": 139.76, "minimum": 37.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 139.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 139.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7620", "type": "HCPCS" } ], "description": "Albuterol ipratrop non-comp", "standard_charges": [ { "billing_class": "facility", "maximum": 0.51, "minimum": 0.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7626", "type": "HCPCS" } ], "description": "Budesonide non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 3.82, "minimum": 2.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7627", "type": "HCPCS" } ], "description": "Budesonide comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 12.28, "minimum": 0.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7631", "type": "HCPCS" } ], "description": "Cromolyn sodium noncomp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 0.57, "minimum": 0.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7633", "type": "HCPCS" } ], "description": "Budesonide non-comp con", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7639", "type": "HCPCS" } ], "description": "Dornase alfa non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 145.23, "minimum": 91.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 125.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 125.4 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 91.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 145.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 145.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7644", "type": "HCPCS" } ], "description": "Ipratropium bromide non-comp", "standard_charges": [ { "billing_class": "facility", "maximum": 1.0, "minimum": 0.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7665", "type": "HCPCS" } ], "description": "Mannitol for inhaler", "standard_charges": [ { "billing_class": "facility", "maximum": 15.4, "minimum": 3.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7669", "type": "HCPCS" } ], "description": "Metaproterenol non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7674", "type": "HCPCS" } ], "description": "Methacholine chloride, neb", "standard_charges": [ { "billing_class": "facility", "maximum": 4.36, "minimum": 2.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.77 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7677", "type": "HCPCS" } ], "description": "Revefenacin inh non-com 1mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.54, "minimum": 0.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7682", "type": "HCPCS" } ], "description": "Tobramycin non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 43.36, "minimum": 27.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 37.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 27.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7686", "type": "HCPCS" } ], "description": "Treprostinil, non-comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 2060.01, "minimum": 1292.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1778.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1778.75 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1292.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2060.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2060.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8501", "type": "HCPCS" } ], "description": "Oral aprepitant", "standard_charges": [ { "billing_class": "facility", "maximum": 7.75, "minimum": 4.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8510", "type": "HCPCS" } ], "description": "Oral busulfan", "standard_charges": [ { "billing_class": "facility", "maximum": 321.45, "minimum": 10.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 321.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 321.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 228.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 228.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8515", "type": "HCPCS" } ], "description": "Cabergoline, oral 0.25mg", "standard_charges": [ { "billing_class": "facility", "maximum": 49.67, "minimum": 5.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8522", "type": "HCPCS" } ], "description": "Capecitabine, oral, 50 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.11, "minimum": 0.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.09 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8530", "type": "HCPCS" } ], "description": "Cyclophosphamide oral 25 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 2.28, "minimum": 1.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8540", "type": "HCPCS" } ], "description": "Oral dexamethasone", "standard_charges": [ { "billing_class": "facility", "maximum": 0.16, "minimum": 0.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8541", "type": "HCPCS" } ], "description": "Oral, hemady, 0.25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.11, "minimum": 0.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8560", "type": "HCPCS" } ], "description": "Etoposide oral 50 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 207.37, "minimum": 77.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 179.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 179.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 130.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 207.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 207.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8562", "type": "HCPCS" } ], "description": "Oral fludarabine phosphate", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8565", "type": "HCPCS" } ], "description": "Gefitinib oral", "standard_charges": [ { "billing_class": "facility", "maximum": 788.61, "minimum": 328.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 328.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 328.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 788.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 788.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8600", "type": "HCPCS" } ], "description": "Melphalan oral 2 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 34.96, "minimum": 21.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 21.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8610", "type": "HCPCS" } ], "description": "Methotrexate oral 2.5 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 0.49, "minimum": 0.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8611", "type": "HCPCS" } ], "description": "Oral methotrexate (jylamvo)", "standard_charges": [ { "billing_class": "facility", "maximum": 51.41, "minimum": 18.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 42.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8612", "type": "HCPCS" } ], "description": "Oral methotrexate (xatmep)", "standard_charges": [ { "billing_class": "facility", "maximum": 56.12, "minimum": 22.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 48.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8650", "type": "HCPCS" } ], "description": "Nabilone oral", "standard_charges": [ { "billing_class": "facility", "maximum": 41.19, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8655", "type": "HCPCS" } ], "description": "Netupitant palonosetron oral", "standard_charges": [ { "billing_class": "facility", "maximum": 1083.65, "minimum": 422.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 422.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 935.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 935.7 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 679.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1083.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1083.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8670", "type": "HCPCS" } ], "description": "Rolapitant, oral, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.39, "minimum": 1.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.79 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8700", "type": "HCPCS" } ], "description": "Temozolomide", "standard_charges": [ { "billing_class": "facility", "maximum": 0.73, "minimum": 0.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J8705", "type": "HCPCS" } ], "description": "Topotecan oral", "standard_charges": [ { "billing_class": "facility", "maximum": 338.56, "minimum": 124.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 292.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 292.34 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 212.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 338.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 338.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87495", "type": "HCPCS" } ], "description": "Cytomeg dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 112.61, "minimum": 30.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87496", "type": "HCPCS" } ], "description": "Cytomeg dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87497", "type": "HCPCS" } ], "description": "Cytomeg dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87498", "type": "HCPCS" } ], "description": "Enterovirus probe&revrs trns", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87500", "type": "HCPCS" } ], "description": "Vanomycin dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87501", "type": "HCPCS" } ], "description": "Influenza dna amp prob 1+", "standard_charges": [ { "billing_class": "facility", "maximum": 192.41, "minimum": 51.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87502", "type": "HCPCS" } ], "description": "Influenza dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 359.25, "minimum": 95.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 95.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 359.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 359.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87503", "type": "HCPCS" } ], "description": "Influenza dna amp prob addl", "standard_charges": [ { "billing_class": "facility", "maximum": 109.58, "minimum": 29.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 109.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87505", "type": "HCPCS" } ], "description": "Nfct agent detection gi", "standard_charges": [ { "billing_class": "facility", "maximum": 481.09, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 481.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 481.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87506", "type": "HCPCS" } ], "description": "Iadna-dna/rna probe tq 6-11", "standard_charges": [ { "billing_class": "facility", "maximum": 986.21, "minimum": 262.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 262.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 986.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 986.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87507", "type": "HCPCS" } ], "description": "Iadna-dna/rna probe tq 12-25", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87510", "type": "HCPCS" } ], "description": "Gardner vag dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87511", "type": "HCPCS" } ], "description": "Gardner vag dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87512", "type": "HCPCS" } ], "description": "Gardner vag dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 156.6, "minimum": 41.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87516", "type": "HCPCS" } ], "description": "Hepatitis b dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87517", "type": "HCPCS" } ], "description": "Hepatitis b dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87520", "type": "HCPCS" } ], "description": "Hepatitis c rna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 117.08, "minimum": 31.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 117.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87521", "type": "HCPCS" } ], "description": "Hepatitis c probe&rvrs trnsc", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87522", "type": "HCPCS" } ], "description": "Hepatitis c revrs trnscrpj", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87523", "type": "HCPCS" } ], "description": "Hepatitis d quantification", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87525", "type": "HCPCS" } ], "description": "Hepatitis g dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 111.75, "minimum": 29.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87526", "type": "HCPCS" } ], "description": "Hepatitis g dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 147.23, "minimum": 39.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 147.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87527", "type": "HCPCS" } ], "description": "Hepatitis g dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 156.6, "minimum": 41.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87528", "type": "HCPCS" } ], "description": "Hsv dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87529", "type": "HCPCS" } ], "description": "Hsv dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87530", "type": "HCPCS" } ], "description": "Hsv dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87531", "type": "HCPCS" } ], "description": "Hhv-6 dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 217.5, "minimum": 58.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 217.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 217.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87532", "type": "HCPCS" } ], "description": "Hhv-6 dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87533", "type": "HCPCS" } ], "description": "Hhv-6 dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 156.6, "minimum": 41.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87534", "type": "HCPCS" } ], "description": "Hiv-1 dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 82.2, "minimum": 21.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87535", "type": "HCPCS" } ], "description": "Hiv-1 probe&reverse trnscrpj", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87536", "type": "HCPCS" } ], "description": "Hiv-1 quant&revrse trnscrpj", "standard_charges": [ { "billing_class": "facility", "maximum": 319.13, "minimum": 85.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 319.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 319.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87537", "type": "HCPCS" } ], "description": "Hiv-2 dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 82.2, "minimum": 21.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87538", "type": "HCPCS" } ], "description": "Hiv-2 probe&revrse trnscripj", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87539", "type": "HCPCS" } ], "description": "Hiv-2 quant&revrse trnscripj", "standard_charges": [ { "billing_class": "facility", "maximum": 219.83, "minimum": 58.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 219.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 219.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87540", "type": "HCPCS" } ], "description": "Legion pneumo dna dir prob", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87541", "type": "HCPCS" } ], "description": "Legion pneumo dna amp prob", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87542", "type": "HCPCS" } ], "description": "Legion pneumo dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 156.6, "minimum": 41.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87550", "type": "HCPCS" } ], "description": "Mycobacteria dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87551", "type": "HCPCS" } ], "description": "Mycobacteria dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 180.9, "minimum": 48.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 180.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 180.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87552", "type": "HCPCS" } ], "description": "Mycobacteria dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87555", "type": "HCPCS" } ], "description": "M.tuberculo dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 100.8, "minimum": 26.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87556", "type": "HCPCS" } ], "description": "M.tuberculo dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 156.3, "minimum": 41.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87557", "type": "HCPCS" } ], "description": "M.tuberculo dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87560", "type": "HCPCS" } ], "description": "M.avium-intra dna dir prob", "standard_charges": [ { "billing_class": "facility", "maximum": 102.34, "minimum": 27.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87561", "type": "HCPCS" } ], "description": "M.avium-intra dna amp prob", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87562", "type": "HCPCS" } ], "description": "M.avium-intra dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87563", "type": "HCPCS" } ], "description": "M. genitalium amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87580", "type": "HCPCS" } ], "description": "M.pneumon dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87581", "type": "HCPCS" } ], "description": "M.pneumon dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87582", "type": "HCPCS" } ], "description": "M.pneumon dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 1134.83, "minimum": 302.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 302.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1134.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1134.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87590", "type": "HCPCS" } ], "description": "N.gonorrhoeae dna dir prob", "standard_charges": [ { "billing_class": "facility", "maximum": 100.8, "minimum": 26.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87591", "type": "HCPCS" } ], "description": "N.gonorrhoeae dna amp prob", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87592", "type": "HCPCS" } ], "description": "N.gonorrhoeae dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87593", "type": "HCPCS" } ], "description": "Orthopoxvirus amp prb each", "standard_charges": [ { "billing_class": "facility", "maximum": 191.89, "minimum": 51.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 191.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 191.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87623", "type": "HCPCS" } ], "description": "Hpv low-risk types", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87624", "type": "HCPCS" } ], "description": "Hpv high-risk types", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87625", "type": "HCPCS" } ], "description": "Hpv types 16 & 18 only", "standard_charges": [ { "billing_class": "facility", "maximum": 152.06, "minimum": 40.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 152.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 152.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87631", "type": "HCPCS" } ], "description": "Resp virus 3-5 targets", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87632", "type": "HCPCS" } ], "description": "Resp virus 6-11 targets", "standard_charges": [ { "billing_class": "facility", "maximum": 817.73, "minimum": 218.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 817.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 817.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87633", "type": "HCPCS" } ], "description": "Resp virus 12-25 targets", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87634", "type": "HCPCS" } ], "description": "Rsv dna/rna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 263.25, "minimum": 70.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 263.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 263.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87635", "type": "HCPCS" } ], "description": "Sars-cov-2 covid-19 amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 192.41, "minimum": 51.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87636", "type": "HCPCS" } ], "description": "Sarscov2 & inf a&b amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87637", "type": "HCPCS" } ], "description": "Sarscov2&inf a&b&rsv amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87640", "type": "HCPCS" } ], "description": "Staph a dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87641", "type": "HCPCS" } ], "description": "Mr-staph dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87650", "type": "HCPCS" } ], "description": "Strep a dna dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87651", "type": "HCPCS" } ], "description": "Strep a dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87652", "type": "HCPCS" } ], "description": "Strep a dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 156.6, "minimum": 41.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87653", "type": "HCPCS" } ], "description": "Strep b dna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87660", "type": "HCPCS" } ], "description": "Trichomonas vagin dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 75.19, "minimum": 20.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87661", "type": "HCPCS" } ], "description": "Trichomonas vaginalis amplif", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87662", "type": "HCPCS" } ], "description": "Zika virus dna/rna amp probe", "standard_charges": [ { "billing_class": "facility", "maximum": 192.41, "minimum": 51.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87797", "type": "HCPCS" } ], "description": "Detect agent nos dna dir", "standard_charges": [ { "billing_class": "facility", "maximum": 112.61, "minimum": 30.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87798", "type": "HCPCS" } ], "description": "Detect agent nos dna amp", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87799", "type": "HCPCS" } ], "description": "Detect agent nos dna quant", "standard_charges": [ { "billing_class": "facility", "maximum": 160.65, "minimum": 42.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 160.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87800", "type": "HCPCS" } ], "description": "Detect agnt mult dna direc", "standard_charges": [ { "billing_class": "facility", "maximum": 163.76, "minimum": 43.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 163.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 163.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87801", "type": "HCPCS" } ], "description": "Detect agnt mult dna ampli", "standard_charges": [ { "billing_class": "facility", "maximum": 263.25, "minimum": 70.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 263.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 263.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87802", "type": "HCPCS" } ], "description": "Strep b assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 47.74, "minimum": 12.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87803", "type": "HCPCS" } ], "description": "Clostridium toxin a w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 60.0, "minimum": 16.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87804", "type": "HCPCS" } ], "description": "Influenza assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 62.06, "minimum": 16.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87806", "type": "HCPCS" } ], "description": "Hiv antigen w/hiv antibodies", "standard_charges": [ { "billing_class": "facility", "maximum": 122.89, "minimum": 32.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 122.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 122.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87807", "type": "HCPCS" } ], "description": "Rsv assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 49.13, "minimum": 13.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87808", "type": "HCPCS" } ], "description": "Trichomonas assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 57.34, "minimum": 15.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87809", "type": "HCPCS" } ], "description": "Adenovirus assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 81.6, "minimum": 21.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87810", "type": "HCPCS" } ], "description": "Chylmd trach assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 132.34, "minimum": 35.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 132.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87811", "type": "HCPCS" } ], "description": "Sars-cov-2 covid19 w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 155.18, "minimum": 41.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 155.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 155.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87850", "type": "HCPCS" } ], "description": "N. gonorrhoeae assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 92.1, "minimum": 24.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87880", "type": "HCPCS" } ], "description": "Strep a assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 61.99, "minimum": 16.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9000", "type": "HCPCS" } ], "description": "Doxorubicin hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 9.0, "minimum": 5.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.77 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9015", "type": "HCPCS" } ], "description": "Aldesleukin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 14366.41, "minimum": 3338.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3338.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12990.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12990.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14366.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14366.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9017", "type": "HCPCS" } ], "description": "Arsenic trioxide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 12.68, "minimum": 7.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.95 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9019", "type": "HCPCS" } ], "description": "Erwinaze injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1310.83, "minimum": 943.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 943.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 943.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1310.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1310.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9020", "type": "HCPCS" } ], "description": "Asparaginase, nos", "standard_charges": [ { "billing_class": "facility", "maximum": 138.51, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 138.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 138.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9021", "type": "HCPCS" } ], "description": "Inj, aspara, rylaze, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 146.72, "minimum": 55.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 126.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 126.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 92.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 146.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 146.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9022", "type": "HCPCS" } ], "description": "Inj, atezolizumab,10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 239.08, "minimum": 91.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 206.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 206.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 149.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 239.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 239.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9023", "type": "HCPCS" } ], "description": "Injection, avelumab, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 262.73, "minimum": 100.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 226.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 226.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 164.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 262.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 262.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9025", "type": "HCPCS" } ], "description": "Azacitidine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.79, "minimum": 0.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9027", "type": "HCPCS" } ], "description": "Clofarabine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 22.93, "minimum": 4.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.8 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9029", "type": "HCPCS" } ], "description": "Inj, adstiladrin, per tx dos", "standard_charges": [ { "billing_class": "facility", "maximum": 171819.53, "minimum": 63342.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 63342.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 148360.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 148360.77 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 107783.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 171819.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 171819.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9030", "type": "HCPCS" } ], "description": "Bcg live intravesical 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 8.13, "minimum": 3.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9032", "type": "HCPCS" } ], "description": "Injection, belinostat, 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 136.26, "minimum": 52.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 117.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 117.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 85.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 136.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 136.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9033", "type": "HCPCS" } ], "description": "Inj., treanda 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.88, "minimum": 1.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9034", "type": "HCPCS" } ], "description": "Inj., bendeka 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 36.45, "minimum": 13.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 31.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 22.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9035", "type": "HCPCS" } ], "description": "Bevacizumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 198.34, "minimum": 73.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 171.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 171.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 124.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 198.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 198.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9036", "type": "HCPCS" } ], "description": "Inj. belrapzo/bendamustine", "standard_charges": [ { "billing_class": "facility", "maximum": 46.42, "minimum": 12.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 40.08 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 29.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9037", "type": "HCPCS" } ], "description": "Inj belantamab mafodont blmf", "standard_charges": [ { "billing_class": "facility", "maximum": 113.09, "minimum": 103.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 103.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 103.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 113.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9039", "type": "HCPCS" } ], "description": "Injection, blinatumomab", "standard_charges": [ { "billing_class": "facility", "maximum": 413.3, "minimum": 164.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 356.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 356.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 259.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 413.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 413.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9040", "type": "HCPCS" } ], "description": "Bleomycin sulfate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 56.67, "minimum": 35.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 48.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 35.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9041", "type": "HCPCS" } ], "description": "Bortezomib injection", "standard_charges": [ { "billing_class": "facility", "maximum": 6.02, "minimum": 3.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9042", "type": "HCPCS" } ], "description": "Brentuximab vedotin inj", "standard_charges": [ { "billing_class": "facility", "maximum": 674.6, "minimum": 258.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 258.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 582.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 582.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 423.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 674.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 674.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9043", "type": "HCPCS" } ], "description": "Cabazitaxel injection", "standard_charges": [ { "billing_class": "facility", "maximum": 607.28, "minimum": 227.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 227.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 524.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 524.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 380.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 607.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 607.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9045", "type": "HCPCS" } ], "description": "Carboplatin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 9.84, "minimum": 6.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9046", "type": "HCPCS" } ], "description": "Inj, bortezomib, dr. reddy's", "standard_charges": [ { "billing_class": "facility", "maximum": 107.17, "minimum": 3.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 107.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 107.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9047", "type": "HCPCS" } ], "description": "Injection, carfilzomib, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 140.84, "minimum": 55.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 121.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 121.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 88.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 140.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9048", "type": "HCPCS" } ], "description": "Inj, bortezomib freseniuskab", "standard_charges": [ { "billing_class": "facility", "maximum": 107.17, "minimum": 6.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 107.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 107.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9049", "type": "HCPCS" } ], "description": "Inj, bortezomib, hospira", "standard_charges": [ { "billing_class": "facility", "maximum": 3.9, "minimum": 2.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9050", "type": "HCPCS" } ], "description": "Carmustine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 691.92, "minimum": 238.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 238.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 597.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 597.45 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 434.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 691.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 691.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9051", "type": "HCPCS" } ], "description": "Inj, bortezomib (maia)", "standard_charges": [ { "billing_class": "facility", "maximum": 8.03, "minimum": 8.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9052", "type": "HCPCS" } ], "description": "Inj, carmustine (accord)", "standard_charges": [ { "billing_class": "facility", "maximum": 573.3, "minimum": 0.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 259.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 573.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 573.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9055", "type": "HCPCS" } ], "description": "Cetuximab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 208.94, "minimum": 78.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 180.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 180.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 131.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 208.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 208.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9056", "type": "HCPCS" } ], "description": "Inj, bendamustine, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 77.64, "minimum": 29.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 67.04 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 48.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9057", "type": "HCPCS" } ], "description": "Inj., copanlisib, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 241.62, "minimum": 204.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 204.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 204.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9060", "type": "HCPCS" } ], "description": "Cisplatin 10 mg injection", "standard_charges": [ { "billing_class": "facility", "maximum": 7.29, "minimum": 4.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9061", "type": "HCPCS" } ], "description": "Inj, amivantamab-vmjw", "standard_charges": [ { "billing_class": "facility", "maximum": 58.43, "minimum": 22.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 50.45 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 36.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9063", "type": "HCPCS" } ], "description": "Inj, elahere, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 184.58, "minimum": 69.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 159.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 159.38 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 115.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 184.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 184.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9065", "type": "HCPCS" } ], "description": "Inj cladribine per 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 30.54, "minimum": 10.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 26.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 19.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9071", "type": "HCPCS" } ], "description": "Inj cyclophosphamd auromedic", "standard_charges": [ { "billing_class": "facility", "maximum": 1.9, "minimum": 0.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.64 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9072", "type": "HCPCS" } ], "description": "Inj cyclophos dr.reddy's 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 28.46, "minimum": 9.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9073", "type": "HCPCS" } ], "description": "Inj cyclophosphamd (ingenus)", "standard_charges": [ { "billing_class": "facility", "maximum": 5.93, "minimum": 0.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9074", "type": "HCPCS" } ], "description": "Inj, cyclophosphamd, sandoz", "standard_charges": [ { "billing_class": "facility", "maximum": 11.79, "minimum": 3.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.18 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9075", "type": "HCPCS" } ], "description": "Inj, cyclophosphamide, nos", "standard_charges": [ { "billing_class": "facility", "maximum": 2.38, "minimum": 0.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9098", "type": "HCPCS" } ], "description": "Cytarabine liposome inj", "standard_charges": [ { "billing_class": "facility", "maximum": 1108.01, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1108.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1108.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9100", "type": "HCPCS" } ], "description": "Cytarabine hcl 100 mg inj", "standard_charges": [ { "billing_class": "facility", "maximum": 2.14, "minimum": 1.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9118", "type": "HCPCS" } ], "description": "Inj. calaspargase pegol-mknl", "standard_charges": [ { "billing_class": "facility", "maximum": 207.4, "minimum": 82.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 82.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 179.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 179.08 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 130.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 207.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 207.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9119", "type": "HCPCS" } ], "description": "Inj., cemiplimab-rwlc, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 76.45, "minimum": 29.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 66.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 66.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 47.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9120", "type": "HCPCS" } ], "description": "Dactinomycin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 880.21, "minimum": 328.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 328.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 760.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 760.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 552.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 880.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 880.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9130", "type": "HCPCS" } ], "description": "Dacarbazine 100 mg inj", "standard_charges": [ { "billing_class": "facility", "maximum": 11.3, "minimum": 7.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9144", "type": "HCPCS" } ], "description": "Daratumumab, hyaluronidase", "standard_charges": [ { "billing_class": "facility", "maximum": 139.27, "minimum": 55.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 120.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 120.25 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 87.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 139.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 139.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9145", "type": "HCPCS" } ], "description": "Injection, daratumumab 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 177.02, "minimum": 71.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 152.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 152.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 111.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 177.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 177.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9150", "type": "HCPCS" } ], "description": "Daunorubicin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 63.74, "minimum": 39.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 55.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 55.04 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 39.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9151", "type": "HCPCS" } ], "description": "Daunorubicin citrate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 140.24, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 140.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9153", "type": "HCPCS" } ], "description": "Inj daunorubicin, cytarabine", "standard_charges": [ { "billing_class": "facility", "maximum": 673.19, "minimum": 256.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 256.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 581.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 581.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 422.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 673.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 673.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9155", "type": "HCPCS" } ], "description": "Degarelix injection", "standard_charges": [ { "billing_class": "facility", "maximum": 11.6, "minimum": 4.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 10.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 7.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9171", "type": "HCPCS" } ], "description": "Docetaxel injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1.98, "minimum": 1.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9172", "type": "HCPCS" } ], "description": "Docetaxel (ingenus), 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 141.49, "minimum": 50.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 122.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 122.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 88.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 141.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 141.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9173", "type": "HCPCS" } ], "description": "Inj., durvalumab, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 227.31, "minimum": 85.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 196.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 196.28 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 142.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 227.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 227.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9175", "type": "HCPCS" } ], "description": "Elliotts b solution per ml", "standard_charges": [ { "billing_class": "facility", "maximum": 31.27, "minimum": 23.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 23.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9176", "type": "HCPCS" } ], "description": "Injection, elotuzumab, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 20.92, "minimum": 7.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.06 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 13.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9177", "type": "HCPCS" } ], "description": "Inj enfort vedo-ejfv 0.25mg", "standard_charges": [ { "billing_class": "facility", "maximum": 99.32, "minimum": 36.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 85.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 85.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 62.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9178", "type": "HCPCS" } ], "description": "Inj, epirubicin hcl, 2 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.42, "minimum": 2.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9179", "type": "HCPCS" } ], "description": "Eribulin mesylate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 361.3, "minimum": 89.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 311.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 311.97 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 226.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 361.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 361.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9181", "type": "HCPCS" } ], "description": "Etoposide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 2.66, "minimum": 1.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.29 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87899", "type": "HCPCS" } ], "description": "Agent nos assay w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 60.26, "minimum": 16.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87900", "type": "HCPCS" } ], "description": "Phenotype infect agent drug", "standard_charges": [ { "billing_class": "facility", "maximum": 488.81, "minimum": 130.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 130.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 488.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 488.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87901", "type": "HCPCS" } ], "description": "Genotype dna hiv reverse t", "standard_charges": [ { "billing_class": "facility", "maximum": 965.44, "minimum": 257.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 257.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 965.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 965.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87902", "type": "HCPCS" } ], "description": "Genotype dna/rna hep c", "standard_charges": [ { "billing_class": "facility", "maximum": 965.44, "minimum": 257.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 257.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 965.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 965.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87903", "type": "HCPCS" } ], "description": "Phenotype dna hiv w/culture", "standard_charges": [ { "billing_class": "facility", "maximum": 1832.48, "minimum": 488.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 488.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1832.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1832.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87904", "type": "HCPCS" } ], "description": "Phenotype dna hiv w/clt add", "standard_charges": [ { "billing_class": "facility", "maximum": 97.76, "minimum": 26.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 97.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 97.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87905", "type": "HCPCS" } ], "description": "Sialidase enzyme assay", "standard_charges": [ { "billing_class": "facility", "maximum": 45.83, "minimum": 12.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87906", "type": "HCPCS" } ], "description": "Genotype dna/rna hiv", "standard_charges": [ { "billing_class": "facility", "maximum": 482.74, "minimum": 128.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 482.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 482.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87910", "type": "HCPCS" } ], "description": "Genotype cytomegalovirus", "standard_charges": [ { "billing_class": "facility", "maximum": 965.44, "minimum": 257.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 257.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 965.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 965.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87912", "type": "HCPCS" } ], "description": "Genotype dna hepatitis b", "standard_charges": [ { "billing_class": "facility", "maximum": 965.44, "minimum": 257.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 257.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 965.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 965.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87913", "type": "HCPCS" } ], "description": "Nfct agt gntyp alys sarscov2", "standard_charges": [ { "billing_class": "facility", "maximum": 965.44, "minimum": 257.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 257.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 965.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 965.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88000", "type": "HCPCS" } ], "description": "Autopsy (necropsy) gross", "standard_charges": [ { "billing_class": "facility", "maximum": 791.7, "minimum": 791.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 791.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 791.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88005", "type": "HCPCS" } ], "description": "Autopsy (necropsy) gross", "standard_charges": [ { "billing_class": "facility", "maximum": 923.85, "minimum": 923.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 923.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 923.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88007", "type": "HCPCS" } ], "description": "Autopsy (necropsy) gross", "standard_charges": [ { "billing_class": "facility", "maximum": 967.05, "minimum": 967.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 967.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 967.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88012", "type": "HCPCS" } ], "description": "Autopsy (necropsy) gross", "standard_charges": [ { "billing_class": "facility", "maximum": 791.7, "minimum": 791.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 791.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 791.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88014", "type": "HCPCS" } ], "description": "Autopsy (necropsy) gross", "standard_charges": [ { "billing_class": "facility", "maximum": 725.63, "minimum": 725.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 725.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 725.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88016", "type": "HCPCS" } ], "description": "Autopsy (necropsy) gross", "standard_charges": [ { "billing_class": "facility", "maximum": 1011.53, "minimum": 1011.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1011.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1011.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88020", "type": "HCPCS" } ], "description": "Autopsy (necropsy) complete", "standard_charges": [ { "billing_class": "facility", "maximum": 1363.54, "minimum": 1363.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1363.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1363.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88025", "type": "HCPCS" } ], "description": "Autopsy (necropsy) complete", "standard_charges": [ { "billing_class": "facility", "maximum": 1319.06, "minimum": 1319.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1319.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1319.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88027", "type": "HCPCS" } ], "description": "Autopsy (necropsy) complete", "standard_charges": [ { "billing_class": "facility", "maximum": 1406.74, "minimum": 1406.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1406.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1406.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88028", "type": "HCPCS" } ], "description": "Autopsy (necropsy) complete", "standard_charges": [ { "billing_class": "facility", "maximum": 791.7, "minimum": 791.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 791.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 791.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88029", "type": "HCPCS" } ], "description": "Autopsy (necropsy) complete", "standard_charges": [ { "billing_class": "facility", "maximum": 791.7, "minimum": 791.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 791.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 791.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88036", "type": "HCPCS" } ], "description": "Limited autopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 395.21, "minimum": 395.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 395.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 395.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88037", "type": "HCPCS" } ], "description": "Limited autopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 352.01, "minimum": 352.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 352.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 352.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88040", "type": "HCPCS" } ], "description": "Forensic autopsy (necropsy)", "standard_charges": [ { "billing_class": "facility", "maximum": 2198.44, "minimum": 2198.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2198.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2198.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88045", "type": "HCPCS" } ], "description": "Coroners autopsy (necropsy)", "standard_charges": [ { "billing_class": "facility", "maximum": 219.83, "minimum": 219.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 219.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 219.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88104", "type": "HCPCS" } ], "description": "Cytopath fl nongyn smears", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88106", "type": "HCPCS" } ], "description": "Cytopath fl nongyn filter", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88108", "type": "HCPCS" } ], "description": "Cytopath concentrate tech", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88112", "type": "HCPCS" } ], "description": "Cytopath cell enhance tech", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9185", "type": "HCPCS" } ], "description": "Fludarabine phosphate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 456.09, "minimum": 286.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 393.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 393.82 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 286.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 456.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 456.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9190", "type": "HCPCS" } ], "description": "Fluorouracil injection", "standard_charges": [ { "billing_class": "facility", "maximum": 6.04, "minimum": 3.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5.22 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9196", "type": "HCPCS" } ], "description": "Inj gemcitabine hcl (accord)", "standard_charges": [ { "billing_class": "facility", "maximum": 25.31, "minimum": 15.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 21.86 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 15.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9198", "type": "HCPCS" } ], "description": "Inj. infugem, 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 88.92, "minimum": 88.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 88.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 88.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9200", "type": "HCPCS" } ], "description": "Floxuridine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 10811.92, "minimum": 4128.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4128.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9335.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9335.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6782.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10811.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10811.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9201", "type": "HCPCS" } ], "description": "Gemcitabine hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 7.78, "minimum": 4.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.72 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9202", "type": "HCPCS" } ], "description": "Goserelin acetate implant", "standard_charges": [ { "billing_class": "facility", "maximum": 1905.29, "minimum": 733.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 733.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1645.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1645.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1195.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1905.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1905.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9203", "type": "HCPCS" } ], "description": "Gemtuzumab ozogamicin 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 631.76, "minimum": 236.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 236.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 545.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 545.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 396.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 631.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 631.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9204", "type": "HCPCS" } ], "description": "Inj mogamulizumab-kpkc, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 659.4, "minimum": 248.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 248.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 569.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 569.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 413.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 659.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 659.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9205", "type": "HCPCS" } ], "description": "Inj irinotecan liposome 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 174.04, "minimum": 66.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 150.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 150.27 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 109.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 174.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 174.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9206", "type": "HCPCS" } ], "description": "Irinotecan injection", "standard_charges": [ { "billing_class": "facility", "maximum": 5.34, "minimum": 3.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9207", "type": "HCPCS" } ], "description": "Ixabepilone injection", "standard_charges": [ { "billing_class": "facility", "maximum": 369.73, "minimum": 139.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 139.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 319.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 319.25 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 231.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 369.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 369.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9208", "type": "HCPCS" } ], "description": "Ifosfamide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 67.94, "minimum": 42.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 58.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 58.66 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 42.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9209", "type": "HCPCS" } ], "description": "Mesna injection", "standard_charges": [ { "billing_class": "facility", "maximum": 4.28, "minimum": 2.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.7 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9210", "type": "HCPCS" } ], "description": "Inj., emapalumab-lzsg, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1020.5, "minimum": 384.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 384.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 881.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 881.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 640.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1020.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1020.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9211", "type": "HCPCS" } ], "description": "Idarubicin hcl injection", "standard_charges": [ { "billing_class": "facility", "maximum": 126.83, "minimum": 79.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 109.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 109.51 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 79.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 126.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 126.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9212", "type": "HCPCS" } ], "description": "Interferon alfacon-1 inj", "standard_charges": [ { "billing_class": "facility", "maximum": 16.67, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9213", "type": "HCPCS" } ], "description": "Interferon alfa-2a inj", "standard_charges": [ { "billing_class": "facility", "maximum": 92.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9214", "type": "HCPCS" } ], "description": "Interferon alfa-2b inj", "standard_charges": [ { "billing_class": "facility", "maximum": 71.91, "minimum": 34.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9215", "type": "HCPCS" } ], "description": "Interferon alfa-n3 inj", "standard_charges": [ { "billing_class": "facility", "maximum": 97.94, "minimum": 70.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 70.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 97.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 97.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9216", "type": "HCPCS" } ], "description": "Interferon gamma 1-b inj", "standard_charges": [ { "billing_class": "facility", "maximum": 26478.11, "minimum": 19052.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19052.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19052.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26478.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26478.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9217", "type": "HCPCS" } ], "description": "Leuprolide acetate suspnsion", "standard_charges": [ { "billing_class": "facility", "maximum": 489.94, "minimum": 176.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 176.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 423.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 423.05 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 307.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 489.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 489.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9218", "type": "HCPCS" } ], "description": "Leuprolide acetate injeciton", "standard_charges": [ { "billing_class": "facility", "maximum": 24.15, "minimum": 15.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 20.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 15.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9219", "type": "HCPCS" } ], "description": "Leuprolide acetate implant", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9223", "type": "HCPCS" } ], "description": "Inj. lurbinectedin, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 555.28, "minimum": 207.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 479.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 479.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 348.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 555.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 555.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9225", "type": "HCPCS" } ], "description": "Vantas implant", "standard_charges": [ { "billing_class": "facility", "maximum": 12359.93, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12359.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12359.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9226", "type": "HCPCS" } ], "description": "Supprelin LA implant", "standard_charges": [ { "billing_class": "facility", "maximum": 122659.48, "minimum": 45020.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45020.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 105912.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 105912.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 76945.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 122659.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 122659.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9227", "type": "HCPCS" } ], "description": "Inj. isatuximab-irfc 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 215.04, "minimum": 81.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 185.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 185.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 134.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 215.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 215.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9228", "type": "HCPCS" } ], "description": "Ipilimumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 487.94, "minimum": 183.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 183.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 421.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 421.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 306.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 487.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 487.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9229", "type": "HCPCS" } ], "description": "Inj inotuzumab ozogam 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 7203.53, "minimum": 2698.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2698.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6220.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6220.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4518.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7203.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7203.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9230", "type": "HCPCS" } ], "description": "Mechlorethamine hcl inj", "standard_charges": [ { "billing_class": "facility", "maximum": 343.63, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 343.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 343.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9245", "type": "HCPCS" } ], "description": "Inj melphalan hydrochl 50 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 362.3, "minimum": 95.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 95.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 312.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 312.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 227.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 362.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 362.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9246", "type": "HCPCS" } ], "description": "Inj., evomela, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 48.78, "minimum": 18.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 42.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 30.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9247", "type": "HCPCS" } ], "description": "Inj, melphalan flufenami 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9248", "type": "HCPCS" } ], "description": "Inj melphalan (hepzato) 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2097.0, "minimum": 795.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 795.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1810.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1810.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1315.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2097.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2097.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9260", "type": "HCPCS" } ], "description": "Methotrexate sodium inj", "standard_charges": [ { "billing_class": "facility", "maximum": 9.13, "minimum": 5.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9261", "type": "HCPCS" } ], "description": "Nelarabine injection", "standard_charges": [ { "billing_class": "facility", "maximum": 202.6, "minimum": 79.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 174.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 174.94 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 127.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 202.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 202.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9262", "type": "HCPCS" } ], "description": "Inj, omacetaxine mep, 0.01mg", "standard_charges": [ { "billing_class": "facility", "maximum": 10.7, "minimum": 8.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9263", "type": "HCPCS" } ], "description": "Oxaliplatin", "standard_charges": [ { "billing_class": "facility", "maximum": 0.22, "minimum": 0.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9264", "type": "HCPCS" } ], "description": "Paclitaxel protein bound", "standard_charges": [ { "billing_class": "facility", "maximum": 36.69, "minimum": 10.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 31.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 23.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9266", "type": "HCPCS" } ], "description": "Pegaspargase injection", "standard_charges": [ { "billing_class": "facility", "maximum": 73361.14, "minimum": 28424.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28424.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63345.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 63345.04 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 46019.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73361.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73361.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9267", "type": "HCPCS" } ], "description": "Paclitaxel injection", "standard_charges": [ { "billing_class": "facility", "maximum": 0.3, "minimum": 0.19, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9268", "type": "HCPCS" } ], "description": "Pentostatin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 7405.16, "minimum": 2608.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2608.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6394.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6394.12 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4645.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7405.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7405.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9269", "type": "HCPCS" } ], "description": "Inj. tagraxofusp-erzs 10 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 918.39, "minimum": 356.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 356.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 793.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 793.0 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 576.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 918.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 918.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9271", "type": "HCPCS" } ], "description": "Inj pembrolizumab", "standard_charges": [ { "billing_class": "facility", "maximum": 156.1, "minimum": 60.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 134.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 134.78 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 97.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9272", "type": "HCPCS" } ], "description": "Inj, dostarlimab-gxly, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 650.56, "minimum": 243.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 243.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 561.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 561.74 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 408.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 650.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 650.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9273", "type": "HCPCS" } ], "description": "Inj tisotu vedotin-tftv, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 492.87, "minimum": 188.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 188.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 425.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 425.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 309.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 492.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 492.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9274", "type": "HCPCS" } ], "description": "Inj, tebentafusp-tebn, 1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 582.0, "minimum": 217.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 217.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 502.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 502.54 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 365.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 582.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 582.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9280", "type": "HCPCS" } ], "description": "Mitomycin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 125.61, "minimum": 20.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 108.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 108.46 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 78.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 125.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 125.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9281", "type": "HCPCS" } ], "description": "Mitomycin instillation", "standard_charges": [ { "billing_class": "facility", "maximum": 843.79, "minimum": 318.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 728.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 728.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 529.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 843.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 843.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9285", "type": "HCPCS" } ], "description": "Inj, olaratumab, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 159.73, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 159.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 159.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9286", "type": "HCPCS" } ], "description": "Inj glofitamab gxbm, 2.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 7509.17, "minimum": 2767.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2767.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6483.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6483.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4710.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7509.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7509.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9293", "type": "HCPCS" } ], "description": "Mitoxantrone hydrochl / 5 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 164.82, "minimum": 23.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 142.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 142.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 103.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 164.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 164.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9294", "type": "HCPCS" } ], "description": "Inj pemetrexed, hospira 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 6.96, "minimum": 3.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.01 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9295", "type": "HCPCS" } ], "description": "Injection, necitumumab, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 15.53, "minimum": 5.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 13.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 9.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9296", "type": "HCPCS" } ], "description": "Inj pemetrexed (accord) 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 26.4, "minimum": 9.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 23.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9297", "type": "HCPCS" } ], "description": "Inj pemetrexed (sandoz) 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.15, "minimum": 2.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9298", "type": "HCPCS" } ], "description": "Inj nivol relatlimab 3mg/1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 525.36, "minimum": 197.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 197.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 453.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 453.63 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 329.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 525.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 525.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9299", "type": "HCPCS" } ], "description": "Injection, nivolumab", "standard_charges": [ { "billing_class": "facility", "maximum": 87.53, "minimum": 32.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 75.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 75.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 54.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 87.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9301", "type": "HCPCS" } ], "description": "Obinutuzumab inj", "standard_charges": [ { "billing_class": "facility", "maximum": 202.79, "minimum": 79.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 175.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 175.1 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 127.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 202.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 202.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9302", "type": "HCPCS" } ], "description": "Ofatumumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 168.64, "minimum": 62.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 141.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 141.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 168.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 168.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9303", "type": "HCPCS" } ], "description": "Panitumumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 449.07, "minimum": 173.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 173.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 387.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 387.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 281.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 449.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 449.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9304", "type": "HCPCS" } ], "description": "Inj. pemetrexed, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 142.82, "minimum": 46.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 123.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 123.32 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 89.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 142.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 142.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9305", "type": "HCPCS" } ], "description": "Pemetrexed injection", "standard_charges": [ { "billing_class": "facility", "maximum": 14.28, "minimum": 4.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 12.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88120", "type": "HCPCS" } ], "description": "Cytp urne 3-5 probes ea spec", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88121", "type": "HCPCS" } ], "description": "Cytp urine 3-5 probes cmptr", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88125", "type": "HCPCS" } ], "description": "Forensic cytopathology", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88130", "type": "HCPCS" } ], "description": "Sex chromatin identification", "standard_charges": [ { "billing_class": "facility", "maximum": 67.43, "minimum": 17.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88140", "type": "HCPCS" } ], "description": "Sex chromatin identification", "standard_charges": [ { "billing_class": "facility", "maximum": 29.96, "minimum": 7.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88141", "type": "HCPCS" } ], "description": "Cytopath c/v interpret", "standard_charges": [ { "billing_class": "facility", "maximum": 86.4, "minimum": 86.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88142", "type": "HCPCS" } ], "description": "Cytopath c/v thin layer", "standard_charges": [ { "billing_class": "facility", "maximum": 75.98, "minimum": 20.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88143", "type": "HCPCS" } ], "description": "Cytopath c/v thin layer redo", "standard_charges": [ { "billing_class": "facility", "maximum": 86.4, "minimum": 23.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88147", "type": "HCPCS" } ], "description": "Cytopath c/v automated", "standard_charges": [ { "billing_class": "facility", "maximum": 189.6, "minimum": 50.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 189.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 189.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88148", "type": "HCPCS" } ], "description": "Cytopath c/v auto rescreen", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88150", "type": "HCPCS" } ], "description": "Cytopath c/v manual", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88152", "type": "HCPCS" } ], "description": "Cytopath c/v auto redo", "standard_charges": [ { "billing_class": "facility", "maximum": 103.65, "minimum": 27.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 103.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 103.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88153", "type": "HCPCS" } ], "description": "Cytopath c/v redo", "standard_charges": [ { "billing_class": "facility", "maximum": 90.11, "minimum": 24.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88155", "type": "HCPCS" } ], "description": "Cytopath c/v index add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 54.94, "minimum": 14.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88160", "type": "HCPCS" } ], "description": "Cytopath smear other source", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88161", "type": "HCPCS" } ], "description": "Cytopath smear other source", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88162", "type": "HCPCS" } ], "description": "Cytopath smear other source", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88164", "type": "HCPCS" } ], "description": "Cytopath tbs c/v manual", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88165", "type": "HCPCS" } ], "description": "Cytopath tbs c/v redo", "standard_charges": [ { "billing_class": "facility", "maximum": 158.33, "minimum": 42.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 158.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 158.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88166", "type": "HCPCS" } ], "description": "Cytopath tbs c/v auto redo", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88167", "type": "HCPCS" } ], "description": "Cytopath tbs c/v select", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88172", "type": "HCPCS" } ], "description": "Cytp dx eval fna 1st ea site", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88173", "type": "HCPCS" } ], "description": "Cytopath eval fna report", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88174", "type": "HCPCS" } ], "description": "Cytopath c/v auto in fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 95.14, "minimum": 25.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88175", "type": "HCPCS" } ], "description": "Cytopath c/v auto fluid redo", "standard_charges": [ { "billing_class": "facility", "maximum": 99.79, "minimum": 26.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88177", "type": "HCPCS" } ], "description": "Cytp fna eval ea addl", "standard_charges": [ { "billing_class": "facility", "maximum": 30.49, "minimum": 30.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88182", "type": "HCPCS" } ], "description": "Cell marker study", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88184", "type": "HCPCS" } ], "description": "Flowcytometry/ tc 1 marker", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 345.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88185", "type": "HCPCS" } ], "description": "Flowcytometry/tc add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 90.23, "minimum": 90.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88187", "type": "HCPCS" } ], "description": "Flowcytometry/read 2-8", "standard_charges": [ { "billing_class": "facility", "maximum": 132.15, "minimum": 132.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 132.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9306", "type": "HCPCS" } ], "description": "Injection, pertuzumab, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 43.87, "minimum": 17.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 37.88 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 27.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9307", "type": "HCPCS" } ], "description": "Pralatrexate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1012.92, "minimum": 392.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 392.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 874.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 874.62 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 635.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1012.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1012.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9308", "type": "HCPCS" } ], "description": "Injection, ramucirumab", "standard_charges": [ { "billing_class": "facility", "maximum": 197.59, "minimum": 74.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 74.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 170.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 170.61 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 123.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 197.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 197.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9309", "type": "HCPCS" } ], "description": "Inj, polatuzumab vedotin 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 360.21, "minimum": 136.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 136.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 311.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 311.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 225.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 360.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 360.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9311", "type": "HCPCS" } ], "description": "Inj rituximab, hyaluronidase", "standard_charges": [ { "billing_class": "facility", "maximum": 99.13, "minimum": 36.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 85.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 85.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 62.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9312", "type": "HCPCS" } ], "description": "Inj., rituximab, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 207.94, "minimum": 75.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 179.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 179.55 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 130.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 207.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 207.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9313", "type": "HCPCS" } ], "description": "Inj., lumoxiti, 0.01 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 63.39, "minimum": 23.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 51.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9314", "type": "HCPCS" } ], "description": "Inj pemetrexed (teva) 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 19.35, "minimum": 12.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 16.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9316", "type": "HCPCS" } ], "description": "Pertuzu, trastuzu, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 173.11, "minimum": 62.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 149.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 149.48 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 108.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 173.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 173.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9317", "type": "HCPCS" } ], "description": "Sacituzumab govitecan-hziy", "standard_charges": [ { "billing_class": "facility", "maximum": 96.04, "minimum": 36.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 82.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 82.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 60.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 96.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 96.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9318", "type": "HCPCS" } ], "description": "Inj romidepsin non-lyo 0.1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 77.29, "minimum": 28.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 74.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 74.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9319", "type": "HCPCS" } ], "description": "Inj romidepsin lyophil 0.1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 82.36, "minimum": 30.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 71.11 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 51.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9320", "type": "HCPCS" } ], "description": "Streptozocin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 1135.71, "minimum": 817.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 817.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 817.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1135.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1135.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9321", "type": "HCPCS" } ], "description": "Inj epcoritamab-bysp 0.16 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 149.56, "minimum": 55.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 129.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 129.14 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 93.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 149.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 149.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9322", "type": "HCPCS" } ], "description": "Inj pemetrexed (bluepoint)", "standard_charges": [ { "billing_class": "facility", "maximum": 22.49, "minimum": 10.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 22.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9323", "type": "HCPCS" } ], "description": "Inj pemetrexed ditromethamin", "standard_charges": [ { "billing_class": "facility", "maximum": 28.59, "minimum": 0.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 25.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9324", "type": "HCPCS" } ], "description": "Inj, pemrydi rtu, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 222.6, "minimum": 75.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 192.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 192.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 139.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 222.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 222.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9325", "type": "HCPCS" } ], "description": "Inj talimogene laherparepvec", "standard_charges": [ { "billing_class": "facility", "maximum": 190.7, "minimum": 73.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 164.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 164.67 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 119.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 190.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 190.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9328", "type": "HCPCS" } ], "description": "Temozolomide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 28.21, "minimum": 10.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9329", "type": "HCPCS" } ], "description": "Inj, tislelizumab-jsgr", "standard_charges": [ { "billing_class": "facility", "maximum": 1494.89, "minimum": 57.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 127.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 127.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1494.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1494.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9330", "type": "HCPCS" } ], "description": "Temsirolimus injection", "standard_charges": [ { "billing_class": "facility", "maximum": 80.0, "minimum": 26.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 69.08 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 50.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 80.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9331", "type": "HCPCS" } ], "description": "Inj sirolimus prot part 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 318.29, "minimum": 84.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 84.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 199.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 318.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 318.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9332", "type": "HCPCS" } ], "description": "Inj efgartigimod 2mg", "standard_charges": [ { "billing_class": "facility", "maximum": 87.94, "minimum": 32.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 75.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 75.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 55.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 87.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9333", "type": "HCPCS" } ], "description": "Inj ronzanolixizum-noli 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 61.84, "minimum": 23.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 53.4 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 38.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9334", "type": "HCPCS" } ], "description": "Inj efgart-alfa 2mg hya-qvfc", "standard_charges": [ { "billing_class": "facility", "maximum": 89.7, "minimum": 33.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 77.45 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 56.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 89.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 89.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9340", "type": "HCPCS" } ], "description": "Thiotepa injection", "standard_charges": [ { "billing_class": "facility", "maximum": 600.94, "minimum": 376.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 518.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 518.9 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 376.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 600.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 600.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9345", "type": "HCPCS" } ], "description": "Inj, retifanlimab-dlwr, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 79.29, "minimum": 30.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 68.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 68.47 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 49.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9347", "type": "HCPCS" } ], "description": "Inj, tremelimumab-actl, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 375.15, "minimum": 140.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 140.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 323.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 323.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 235.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 375.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 375.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9348", "type": "HCPCS" } ], "description": "Inj. naxitamab-gqgk, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1740.61, "minimum": 686.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 686.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1502.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1502.96 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1091.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1740.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1740.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9349", "type": "HCPCS" } ], "description": "Inj., tafasitamab-cxix", "standard_charges": [ { "billing_class": "facility", "maximum": 37.86, "minimum": 14.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 32.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 23.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9350", "type": "HCPCS" } ], "description": "Inj mosunetuzumab-axgb, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1737.3, "minimum": 654.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 654.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1500.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1500.1 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1089.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1737.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1737.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9351", "type": "HCPCS" } ], "description": "Topotecan injection", "standard_charges": [ { "billing_class": "facility", "maximum": 4.82, "minimum": 3.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88188", "type": "HCPCS" } ], "description": "Flowcytometry/read 9-15", "standard_charges": [ { "billing_class": "facility", "maximum": 231.26, "minimum": 231.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 231.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 231.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88189", "type": "HCPCS" } ], "description": "Flowcytometry/read 16 & >", "standard_charges": [ { "billing_class": "facility", "maximum": 312.6, "minimum": 312.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 312.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 312.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88199", "type": "HCPCS" } ], "description": "Cytopathology procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88230", "type": "HCPCS" } ], "description": "Tissue culture lymphocyte", "standard_charges": [ { "billing_class": "facility", "maximum": 436.84, "minimum": 116.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 436.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 436.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88233", "type": "HCPCS" } ], "description": "Tissue culture skin/biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 527.74, "minimum": 140.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 140.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 527.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 527.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88235", "type": "HCPCS" } ], "description": "Tissue culture placenta", "standard_charges": [ { "billing_class": "facility", "maximum": 563.63, "minimum": 150.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 563.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 563.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88237", "type": "HCPCS" } ], "description": "Tissue culture bone marrow", "standard_charges": [ { "billing_class": "facility", "maximum": 539.06, "minimum": 143.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 143.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 539.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 539.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88239", "type": "HCPCS" } ], "description": "Tissue culture tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 553.2, "minimum": 147.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 147.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 553.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 553.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88240", "type": "HCPCS" } ], "description": "Cell cryopreserve/storage", "standard_charges": [ { "billing_class": "facility", "maximum": 49.01, "minimum": 13.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88241", "type": "HCPCS" } ], "description": "Frozen cell preparation", "standard_charges": [ { "billing_class": "facility", "maximum": 45.34, "minimum": 12.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88245", "type": "HCPCS" } ], "description": "Chromosome analysis 20-25", "standard_charges": [ { "billing_class": "facility", "maximum": 649.39, "minimum": 173.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 173.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 649.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 649.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88248", "type": "HCPCS" } ], "description": "Chromosome analysis 50-100", "standard_charges": [ { "billing_class": "facility", "maximum": 649.39, "minimum": 173.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 173.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 649.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 649.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88249", "type": "HCPCS" } ], "description": "Chromosome analysis 100", "standard_charges": [ { "billing_class": "facility", "maximum": 649.39, "minimum": 173.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 173.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 649.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 649.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88261", "type": "HCPCS" } ], "description": "Chromosome analysis 5", "standard_charges": [ { "billing_class": "facility", "maximum": 991.28, "minimum": 264.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 264.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 991.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 991.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88262", "type": "HCPCS" } ], "description": "Chromosome analysis 15-20", "standard_charges": [ { "billing_class": "facility", "maximum": 470.59, "minimum": 125.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 125.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 470.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 470.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88263", "type": "HCPCS" } ], "description": "Chromosome analysis 45", "standard_charges": [ { "billing_class": "facility", "maximum": 563.59, "minimum": 150.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 563.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 563.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88264", "type": "HCPCS" } ], "description": "Chromosome analysis 20-25", "standard_charges": [ { "billing_class": "facility", "maximum": 542.29, "minimum": 144.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 144.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 542.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 542.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88267", "type": "HCPCS" } ], "description": "Chromosome analys placenta", "standard_charges": [ { "billing_class": "facility", "maximum": 707.14, "minimum": 188.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 188.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 707.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 707.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88269", "type": "HCPCS" } ], "description": "Chromosome analys amniotic", "standard_charges": [ { "billing_class": "facility", "maximum": 651.23, "minimum": 173.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 173.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 651.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 651.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88271", "type": "HCPCS" } ], "description": "Cytogenetics dna probe", "standard_charges": [ { "billing_class": "facility", "maximum": 80.33, "minimum": 21.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 80.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88272", "type": "HCPCS" } ], "description": "Cytogenetics 3-5", "standard_charges": [ { "billing_class": "facility", "maximum": 152.63, "minimum": 40.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 152.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 152.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88273", "type": "HCPCS" } ], "description": "Cytogenetics 10-30", "standard_charges": [ { "billing_class": "facility", "maximum": 130.54, "minimum": 34.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 130.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 130.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88274", "type": "HCPCS" } ], "description": "Cytogenetics 25-99", "standard_charges": [ { "billing_class": "facility", "maximum": 158.93, "minimum": 42.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 158.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 158.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88275", "type": "HCPCS" } ], "description": "Cytogenetics 100-300", "standard_charges": [ { "billing_class": "facility", "maximum": 191.96, "minimum": 51.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 191.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 191.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88280", "type": "HCPCS" } ], "description": "Chromosome karyotype study", "standard_charges": [ { "billing_class": "facility", "maximum": 125.51, "minimum": 33.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 125.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 125.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88283", "type": "HCPCS" } ], "description": "Chromosome banding study", "standard_charges": [ { "billing_class": "facility", "maximum": 257.25, "minimum": 68.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 257.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 257.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88285", "type": "HCPCS" } ], "description": "Chromosome count additional", "standard_charges": [ { "billing_class": "facility", "maximum": 100.91, "minimum": 26.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88289", "type": "HCPCS" } ], "description": "Chromosome study additional", "standard_charges": [ { "billing_class": "facility", "maximum": 129.11, "minimum": 34.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 129.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 129.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88291", "type": "HCPCS" } ], "description": "Cyto/molecular report", "standard_charges": [ { "billing_class": "facility", "maximum": 121.99, "minimum": 121.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 121.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 121.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88299", "type": "HCPCS" } ], "description": "Cytogenetic study", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9352", "type": "HCPCS" } ], "description": "Injection trabectedin 0.1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 983.05, "minimum": 391.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 848.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 848.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 616.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 983.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 983.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9353", "type": "HCPCS" } ], "description": "Inj. margetuximab-cmkb, 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 133.87, "minimum": 52.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 115.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 115.6 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 83.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 133.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 133.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9354", "type": "HCPCS" } ], "description": "Inj, ado-trastuzumab emt 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 111.03, "minimum": 42.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 95.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 95.87 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 69.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9355", "type": "HCPCS" } ], "description": "Trastuzumab injection", "standard_charges": [ { "billing_class": "facility", "maximum": 208.81, "minimum": 75.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 180.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 180.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 130.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 208.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 208.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9356", "type": "HCPCS" } ], "description": "Inj. herceptin hylecta, 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 170.89, "minimum": 61.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 147.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 147.56 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 107.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 170.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 170.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9357", "type": "HCPCS" } ], "description": "Valrubicin injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3773.73, "minimum": 1323.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1323.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3258.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3258.5 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2367.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3773.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3773.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9358", "type": "HCPCS" } ], "description": "Inj fam-trastu deru-nxki 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 78.08, "minimum": 29.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 67.42 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 48.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9359", "type": "HCPCS" } ], "description": "Inj lon tesirin-lpyl 0.075mg", "standard_charges": [ { "billing_class": "facility", "maximum": 574.85, "minimum": 216.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 216.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 496.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 496.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 360.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 574.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 574.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9360", "type": "HCPCS" } ], "description": "Vinblastine sulfate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 13.09, "minimum": 8.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.3 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 8.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9370", "type": "HCPCS" } ], "description": "Vincristine sulfate 1 MG inj", "standard_charges": [ { "billing_class": "facility", "maximum": 22.57, "minimum": 14.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 19.49 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 14.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9376", "type": "HCPCS" } ], "description": "Inj pozelimab-bbfg, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 281.43, "minimum": 91.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 202.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 202.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 281.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 281.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9380", "type": "HCPCS" } ], "description": "Inj teclistamab cqyv 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 88.21, "minimum": 33.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 76.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 76.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 55.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 88.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9381", "type": "HCPCS" } ], "description": "Inj teplizumab mzwv 5 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 100.92, "minimum": 37.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 87.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 87.14 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 63.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9390", "type": "HCPCS" } ], "description": "Vinorelbine tartrate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 17.62, "minimum": 11.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9393", "type": "HCPCS" } ], "description": "Inj, fulvestrant (teva)", "standard_charges": [ { "billing_class": "facility", "maximum": 57.45, "minimum": 41.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 46.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9394", "type": "HCPCS" } ], "description": "Inj, fulvestrant (fresenius)", "standard_charges": [ { "billing_class": "facility", "maximum": 33.22, "minimum": 20.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.69 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 20.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9395", "type": "HCPCS" } ], "description": "Injection, Fulvestrant", "standard_charges": [ { "billing_class": "facility", "maximum": 18.05, "minimum": 11.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.58 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9400", "type": "HCPCS" } ], "description": "Inj, ziv-aflibercept, 1mg", "standard_charges": [ { "billing_class": "facility", "maximum": 21.63, "minimum": 7.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.67 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 13.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J9600", "type": "HCPCS" } ], "description": "Porfimer sodium injection", "standard_charges": [ { "billing_class": "facility", "maximum": 65659.02, "minimum": 24228.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24228.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 54575.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 54575.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65659.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65659.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8605", "type": "HCPCS" } ], "description": "Inj bulking agent anal canal", "standard_charges": [ { "billing_class": "facility", "maximum": 3433.81, "minimum": 2019.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3433.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3433.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2019.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2019.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9023", "type": "HCPCS" } ], "description": "Frozen plasma, pooled, sd", "standard_charges": [ { "billing_class": "facility", "maximum": 55.96, "minimum": 1.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9041", "type": "HCPCS" } ], "description": "Albumin (human),5%, 50ml", "standard_charges": [ { "billing_class": "facility", "maximum": 28.78, "minimum": 10.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 24.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 18.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9043", "type": "HCPCS" } ], "description": "Plasma protein fract,5%,50ml", "standard_charges": [ { "billing_class": "facility", "maximum": 52.7, "minimum": 8.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 52.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9045", "type": "HCPCS" } ], "description": "Albumin (human), 5%, 250 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 143.85, "minimum": 53.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 124.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 124.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 90.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 143.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 143.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9046", "type": "HCPCS" } ], "description": "Albumin (human), 25%, 20 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 57.53, "minimum": 21.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 49.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 36.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9047", "type": "HCPCS" } ], "description": "Albumin (human), 25%, 50ml", "standard_charges": [ { "billing_class": "facility", "maximum": 143.85, "minimum": 53.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 124.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 124.21 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 90.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 143.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 143.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9048", "type": "HCPCS" } ], "description": "Plasmaprotein fract,5%,250ml", "standard_charges": [ { "billing_class": "facility", "maximum": 123.76, "minimum": 35.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 123.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 123.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0138", "type": "HCPCS" } ], "description": "Ferumoxytol, non-esrd", "standard_charges": [ { "billing_class": "facility", "maximum": 1.03, "minimum": 0.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0139", "type": "HCPCS" } ], "description": "Ferumoxytol, esrd use", "standard_charges": [ { "billing_class": "facility", "maximum": 1.03, "minimum": 0.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.89 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0144", "type": "HCPCS" } ], "description": "Azithromycin dihydrate, oral", "standard_charges": [ { "billing_class": "facility", "maximum": 57.8, "minimum": 34.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 57.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0161", "type": "HCPCS" } ], "description": "Chlorpromazine hcl 5mg oral", "standard_charges": [ { "billing_class": "facility", "maximum": 0.82, "minimum": 0.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0162", "type": "HCPCS" } ], "description": "Ondansetron oral", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0163", "type": "HCPCS" } ], "description": "Diphenhydramine HCl 50mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.52, "minimum": 0.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0164", "type": "HCPCS" } ], "description": "Prochlorperazine maleate 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.14, "minimum": 0.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0166", "type": "HCPCS" } ], "description": "Granisetron HCl 1 mg oral", "standard_charges": [ { "billing_class": "facility", "maximum": 139.84, "minimum": 7.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 139.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 139.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0167", "type": "HCPCS" } ], "description": "Dronabinol 2.5mg oral", "standard_charges": [ { "billing_class": "facility", "maximum": 5.01, "minimum": 3.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0169", "type": "HCPCS" } ], "description": "Promethazine HCl 12.5mg oral", "standard_charges": [ { "billing_class": "facility", "maximum": 0.76, "minimum": 0.19, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0175", "type": "HCPCS" } ], "description": "Perphenazine 4mg oral", "standard_charges": [ { "billing_class": "facility", "maximum": 1.76, "minimum": 1.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0177", "type": "HCPCS" } ], "description": "Hydroxyzine pamoate 25mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.26, "minimum": 0.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0180", "type": "HCPCS" } ], "description": "Dolasetron mesylate oral", "standard_charges": [ { "billing_class": "facility", "maximum": 389.62, "minimum": 141.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 141.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 141.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 389.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 389.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0220", "type": "HCPCS" } ], "description": "Tixagev and cilgav, 300mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0221", "type": "HCPCS" } ], "description": "Tixagev and cilgav, 600mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0222", "type": "HCPCS" } ], "description": "Bebtelovimab 175 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 6829.2, "minimum": 5601.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5601.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5601.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6829.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6829.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0224", "type": "HCPCS" } ], "description": "Inj, pemivibart, 4500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 17841.29, "minimum": 11191.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15405.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15405.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 11191.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17841.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17841.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0240", "type": "HCPCS" } ], "description": "Casirivi and imdevi 600 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0243", "type": "HCPCS" } ], "description": "Casirivimab and imdevimab", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0244", "type": "HCPCS" } ], "description": "Casirivi and imdevi 1200 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0245", "type": "HCPCS" } ], "description": "Bamlanivimab and etesevima", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0247", "type": "HCPCS" } ], "description": "Sotrovimab", "standard_charges": [ { "billing_class": "facility", "maximum": 6829.2, "minimum": 5601.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5601.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5601.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6829.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6829.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0249", "type": "HCPCS" } ], "description": "Tocilizumab for covid-19", "standard_charges": [ { "billing_class": "facility", "maximum": 20.51, "minimum": 12.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 17.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0515", "type": "HCPCS" } ], "description": "Sermorelin acetate injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3.5, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2004", "type": "HCPCS" } ], "description": "Bladder calculi irrig sol", "standard_charges": [ { "billing_class": "facility", "maximum": 231.0, "minimum": 37.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 231.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 231.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2009", "type": "HCPCS" } ], "description": "Fosphenytoin inj pe", "standard_charges": [ { "billing_class": "facility", "maximum": 22.63, "minimum": 1.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2017", "type": "HCPCS" } ], "description": "Teniposide, 50 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 8116.83, "minimum": 5840.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 5840.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 5840.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8116.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8116.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2028", "type": "HCPCS" } ], "description": "Inj, sculptra, 0.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.71, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2035", "type": "HCPCS" } ], "description": "Afluria vacc, 3 yrs & >, im", "standard_charges": [ { "billing_class": "facility", "maximum": 67.15, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2036", "type": "HCPCS" } ], "description": "Flulaval vacc, 3 yrs & >, im", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2037", "type": "HCPCS" } ], "description": "Fluvirin vacc, 3 yrs & >, im", "standard_charges": [ { "billing_class": "facility", "maximum": 32.44, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2038", "type": "HCPCS" } ], "description": "Fluzone vacc, 3 yrs & >, im", "standard_charges": [ { "billing_class": "facility", "maximum": 134.47, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 134.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 134.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2041", "type": "HCPCS" } ], "description": "Axicabtagene ciloleucel car+", "standard_charges": [ { "billing_class": "facility", "maximum": 1326591.48, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 533230.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 832179.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1326591.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1326591.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2042", "type": "HCPCS" } ], "description": "Tisagenlecleucel car-pos t", "standard_charges": [ { "billing_class": "facility", "maximum": 1532840.61, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 591726.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 961560.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1532840.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1532840.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2043", "type": "HCPCS" } ], "description": "Sipuleucel-t auto cd54+", "standard_charges": [ { "billing_class": "facility", "maximum": 150503.92, "minimum": 55272.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55272.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 129955.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 129955.41 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 94412.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 150503.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 150503.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2049", "type": "HCPCS" } ], "description": "Imported Lipodox inj", "standard_charges": [ { "billing_class": "facility", "maximum": 1433.21, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 298.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1433.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1433.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2050", "type": "HCPCS" } ], "description": "Doxorubicin inj 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 368.7, "minimum": 108.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 318.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 318.36 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 231.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 368.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 368.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88300", "type": "HCPCS" } ], "description": "Surgical path gross", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88302", "type": "HCPCS" } ], "description": "Tissue exam by pathologist", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88304", "type": "HCPCS" } ], "description": "Tissue exam by pathologist", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88305", "type": "HCPCS" } ], "description": "Tissue exam by pathologist", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88307", "type": "HCPCS" } ], "description": "Tissue exam by pathologist", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 345.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88309", "type": "HCPCS" } ], "description": "Tissue exam by pathologist", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88311", "type": "HCPCS" } ], "description": "Decalcify tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 31.76, "minimum": 31.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88312", "type": "HCPCS" } ], "description": "Special stains group 1", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88313", "type": "HCPCS" } ], "description": "Special stains group 2", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 127.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88314", "type": "HCPCS" } ], "description": "Histochemical stains add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 266.85, "minimum": 266.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 266.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 266.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88319", "type": "HCPCS" } ], "description": "Enzyme histochemistry", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88321", "type": "HCPCS" } ], "description": "Microslide consultation", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88323", "type": "HCPCS" } ], "description": "Microslide consultation", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88325", "type": "HCPCS" } ], "description": "Comprehensive review of data", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88329", "type": "HCPCS" } ], "description": "Path consult introp", "standard_charges": [ { "billing_class": "facility", "maximum": 127.35, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 127.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88331", "type": "HCPCS" } ], "description": "Path consult intraop 1 bloc", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88332", "type": "HCPCS" } ], "description": "Path consult intraop addl", "standard_charges": [ { "billing_class": "facility", "maximum": 94.05, "minimum": 94.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88333", "type": "HCPCS" } ], "description": 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"methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88346", "type": "HCPCS" } ], "description": "Immunofluor antb 1st stain", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88348", "type": "HCPCS" } ], "description": "Electron microscopy", 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schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 334.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88355", "type": "HCPCS" } ], "description": "Analysis skeletal muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88356", "type": "HCPCS" } ], "description": "Analysis nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88358", "type": "HCPCS" } ], "description": "Analysis tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88360", "type": "HCPCS" } ], "description": "Tumor immunohistochem/manual", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88361", "type": "HCPCS" } ], "description": "Tumor immunohistochem/comput", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 345.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88362", "type": "HCPCS" } ], "description": "Nerve teasing preparations", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88363", "type": "HCPCS" } ], "description": "Xm archive tissue molec anal", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88364", "type": "HCPCS" } ], "description": "Insitu hybridization (fish)", "standard_charges": [ { "billing_class": "facility", "maximum": 391.39, "minimum": 391.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 391.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 391.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88365", "type": "HCPCS" } ], "description": "Insitu hybridization (fish)", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88366", "type": "HCPCS" } ], "description": "Insitu hybridization (fish)", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88367", "type": "HCPCS" } ], "description": "Insitu hybridization auto", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 345.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88368", "type": "HCPCS" } ], "description": "Insitu hybridization manual", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 345.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88369", "type": "HCPCS" } ], "description": "M/phmtrc alysishquant/semiq", "standard_charges": [ { "billing_class": "facility", "maximum": 340.58, "minimum": 340.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 340.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 340.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88371", "type": "HCPCS" } ], "description": "Protein western blot tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 83.36, "minimum": 83.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88372", "type": "HCPCS" } ], "description": "Protein analysis w/probe", "standard_charges": [ { "billing_class": "facility", "maximum": 98.33, "minimum": 98.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 98.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 98.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88373", "type": "HCPCS" } ], "description": "M/phmtrc alys ishquant/semiq", "standard_charges": [ { "billing_class": "facility", "maximum": 166.46, "minimum": 166.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 166.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 166.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88374", "type": "HCPCS" } ], "description": "M/phmtrc alys ishquant/semiq", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88375", "type": "HCPCS" } ], "description": "Optical endomicroscpy interp", "standard_charges": [ { "billing_class": "facility", "maximum": 177.9, "minimum": 177.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 177.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 177.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88377", "type": "HCPCS" } ], "description": "M/phmtrc alys ishquant/semiq", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88380", "type": "HCPCS" } ], "description": "Microdissection laser", "standard_charges": [ { "billing_class": "facility", "maximum": 269.4, "minimum": 269.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 269.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 269.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88381", "type": "HCPCS" } ], "description": "Microdissection manual", "standard_charges": [ { "billing_class": "facility", "maximum": 677.33, "minimum": 677.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 677.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 677.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88387", "type": "HCPCS" } ], "description": "Tiss exam molecular study", "standard_charges": [ { "billing_class": "facility", "maximum": 29.21, "minimum": 29.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88388", "type": "HCPCS" } ], "description": "Tiss ex molecul study add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 52.09, "minimum": 52.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88399", "type": "HCPCS" } ], "description": "Surgical pathology procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88720", "type": "HCPCS" } ], "description": "Bilirubin total transcut", "standard_charges": [ { "billing_class": "facility", "maximum": 18.83, "minimum": 5.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88738", "type": "HCPCS" } ], "description": "Hgb quant transcutaneous", "standard_charges": [ { "billing_class": "facility", "maximum": 18.83, "minimum": 5.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88740", "type": "HCPCS" } ], "description": "Transcutaneous carboxyhb", "standard_charges": [ { "billing_class": "facility", "maximum": 35.14, "minimum": 9.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "88741", "type": "HCPCS" } ], "description": "Transcutaneous methb", "standard_charges": [ { "billing_class": "facility", "maximum": 35.14, "minimum": 9.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89049", "type": "HCPCS" } ], "description": "Chct for mal hyperthermia", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89050", "type": "HCPCS" } ], "description": "Body fluid cell count", "standard_charges": [ { "billing_class": "facility", "maximum": 17.7, "minimum": 4.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89051", "type": "HCPCS" } ], "description": "Body fluid cell count", "standard_charges": [ { "billing_class": "facility", "maximum": 21.0, "minimum": 5.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89055", "type": "HCPCS" } ], "description": "Leukocyte assessment fecal", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89060", "type": "HCPCS" } ], "description": "Exam synovial fluid crystals", "standard_charges": [ { "billing_class": "facility", "maximum": 27.49, "minimum": 7.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89125", "type": "HCPCS" } ], "description": "Specimen fat stain", "standard_charges": [ { "billing_class": "facility", "maximum": 22.05, "minimum": 5.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89160", "type": "HCPCS" } ], "description": "Exam feces for meat fibers", "standard_charges": [ { "billing_class": "facility", "maximum": 18.19, "minimum": 4.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2053", "type": "HCPCS" } ], "description": "Brexucabtagene car pos t", "standard_charges": [ { "billing_class": "facility", "maximum": 1322619.59, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 489304.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 829687.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1322619.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1322619.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2054", "type": "HCPCS" } ], "description": "Lisocabtagene mara car pos t", "standard_charges": [ { "billing_class": "facility", "maximum": 1399676.98, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 562538.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 878026.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1399676.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1399676.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2055", "type": "HCPCS" } ], "description": "Idecabtagene vicleucel car", "standard_charges": [ { "billing_class": "facility", "maximum": 1431726.69, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 557317.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 898131.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1431726.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1431726.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2056", "type": "HCPCS" } ], "description": "Ciltacabtagene car-pos t", "standard_charges": [ { "billing_class": "facility", "maximum": 1494072.7, "minimum": 0.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 565868.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 937241.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1494072.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1494072.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q3027", "type": "HCPCS" } ], "description": "Inj beta interferon im 1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 150.73, "minimum": 94.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 130.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 130.15 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 94.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 150.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 150.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q3028", "type": "HCPCS" } ], "description": "Inj beta interferon sq 1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 126.99, "minimum": 93.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 93.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 93.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 126.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 126.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4074", "type": "HCPCS" } ], "description": "Iloprost non-comp unit dose", "standard_charges": [ { "billing_class": "facility", "maximum": 401.73, "minimum": 252.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 346.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 346.88 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 252.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 401.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 401.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4081", "type": "HCPCS" } ], "description": "Epoetin alfa, 100 units ESRD", "standard_charges": [ { "billing_class": "facility", "maximum": 1.76, "minimum": 1.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5101", "type": "HCPCS" } ], "description": "Inj filgrastim gcsf biosimil", "standard_charges": [ { "billing_class": "facility", "maximum": 0.98, "minimum": 0.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.84 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5103", "type": "HCPCS" } ], "description": "Injection, inflectra", "standard_charges": [ { "billing_class": "facility", "maximum": 31.3, "minimum": 19.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 27.03 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 19.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5104", "type": "HCPCS" } ], "description": "Injection, renflexis", "standard_charges": [ { "billing_class": "facility", "maximum": 71.16, "minimum": 27.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 61.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 61.45 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 44.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5105", "type": "HCPCS" } ], "description": "Inj Retacrit esrd on dialysi", "standard_charges": [ { "billing_class": "facility", "maximum": 2.03, "minimum": 1.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5106", "type": "HCPCS" } ], "description": "Inj Retacrit non-esrd use", "standard_charges": [ { "billing_class": "facility", "maximum": 20.24, "minimum": 7.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 17.48 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5107", "type": "HCPCS" } ], "description": "Inj mvasi 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 77.86, "minimum": 27.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 67.23 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 48.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5108", "type": "HCPCS" } ], "description": "Injection, fulphila", "standard_charges": [ { "billing_class": "facility", "maximum": 339.56, "minimum": 99.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 99.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 293.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 293.2 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 213.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 339.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 339.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5110", "type": "HCPCS" } ], "description": "Nivestym", "standard_charges": [ { "billing_class": "facility", "maximum": 0.79, "minimum": 0.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5111", "type": "HCPCS" } ], "description": "Injection, udenyca 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 367.34, "minimum": 106.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 106.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 317.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 317.19 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 230.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 367.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 367.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5112", "type": "HCPCS" } ], "description": "Inj ontruzant 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 71.46, "minimum": 19.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 61.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 61.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 44.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5113", "type": "HCPCS" } ], "description": "Inj herzuma 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 195.07, "minimum": 69.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 168.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 168.43 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 122.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 195.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 195.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5114", "type": "HCPCS" } ], "description": "Inj ogivri 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 140.49, "minimum": 40.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 121.31 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 88.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 140.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5115", "type": "HCPCS" } ], "description": "Inj truxima 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 86.26, "minimum": 29.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 74.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 74.48 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 54.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5116", "type": "HCPCS" } ], "description": "Inj., trazimera, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 51.41, "minimum": 27.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 44.39 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 32.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5117", "type": "HCPCS" } ], "description": "Inj., kanjinti, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 94.01, "minimum": 47.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 81.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 81.17 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 58.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5118", "type": "HCPCS" } ], "description": "Inj., zirabev, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 62.33, "minimum": 25.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 53.82 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 39.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5119", "type": "HCPCS" } ], "description": "Inj ruxience, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 63.93, "minimum": 27.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 55.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 55.2 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 40.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5120", "type": "HCPCS" } ], "description": "Inj pegfilgrastim-bmez 0.5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 66.96, "minimum": 30.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 57.82 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 42.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5121", "type": "HCPCS" } ], "description": "Inj. avsola, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 53.74, "minimum": 20.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 46.4 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 33.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5122", "type": "HCPCS" } ], "description": "Inj, nyvepria", "standard_charges": [ { "billing_class": "facility", "maximum": 317.1, "minimum": 131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 273.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 273.8 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 198.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 317.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 317.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5123", "type": "HCPCS" } ], "description": "Inj. riabni, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 99.67, "minimum": 26.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 86.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 86.07 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 62.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5124", "type": "HCPCS" } ], "description": "Inj. byooviz, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 458.53, "minimum": 61.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 395.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 395.93 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 287.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5125", "type": "HCPCS" } ], "description": "Inj, releuko 1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.22, "minimum": 0.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.05 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5126", "type": "HCPCS" } ], "description": "Inj alymsys 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 157.8, "minimum": 37.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 136.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 136.26 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 98.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 157.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 157.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5127", "type": "HCPCS" } ], "description": "Inj, stimufend, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 808.42, "minimum": 184.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 184.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 698.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 698.05 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 507.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 808.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 808.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5128", "type": "HCPCS" } ], "description": "Inj, cimerli, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 457.29, "minimum": 86.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 394.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 394.85 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 286.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 457.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 457.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5129", "type": "HCPCS" } ], "description": "Inj, vegzelma, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 140.92, "minimum": 39.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 121.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 121.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 88.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 140.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5130", "type": "HCPCS" } ], "description": "Inj, fylnetra, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 497.34, "minimum": 137.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 429.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 429.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 311.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 497.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 497.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5133", "type": "HCPCS" } ], "description": "Inj, tofidence, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 16.26, "minimum": 5.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 14.04 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 10.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5135", "type": "HCPCS" } ], "description": "Inj, tyenne, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 11.14, "minimum": 4.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 9.62 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 6.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9950", "type": "HCPCS" } ], "description": "Inj sulf hexa lipid microsph", "standard_charges": [ { "billing_class": "facility", "maximum": 50.62, "minimum": 31.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 43.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 43.71 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 31.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9953", "type": "HCPCS" } ], "description": "Inj fe-based mr contrast,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9954", "type": "HCPCS" } ], "description": "Oral MR contrast, 100 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9956", "type": "HCPCS" } ], "description": "Inj octafluoropropane mic,ml", "standard_charges": [ { "billing_class": "facility", "maximum": 112.76, "minimum": 70.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 97.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 97.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 70.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9957", "type": "HCPCS" } ], "description": "Inj perflutren lip micros,ml", "standard_charges": [ { "billing_class": "facility", "maximum": 112.76, "minimum": 70.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 97.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 97.37 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 70.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9958", "type": "HCPCS" } ], "description": "HOCM <=149 mg/ml iodine, 1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.19, "minimum": 0.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9960", "type": "HCPCS" } ], "description": "HOCM 200-249mg/ml iodine,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9961", "type": "HCPCS" } ], "description": "HOCM 250-299mg/ml iodine,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.79, "minimum": 0.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.68 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9962", "type": "HCPCS" } ], "description": "HOCM 300-349mg/ml iodine,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9963", "type": "HCPCS" } ], "description": "HOCM 350-399mg/ml iodine,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.6, "minimum": 0.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.51 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9964", "type": "HCPCS" } ], "description": "Hocm>= 400mg/ml iodine, 1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9965", "type": "HCPCS" } ], "description": "LOCM 100-199mg/ml iodine,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 3.25, "minimum": 2.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.81 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9966", "type": "HCPCS" } ], "description": "LOCM 200-299mg/ml iodine,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 1.11, "minimum": 0.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.96 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9967", "type": "HCPCS" } ], "description": "LOCM 300-399mg/ml iodine,1ml", "standard_charges": [ { "billing_class": "facility", "maximum": 0.38, "minimum": 0.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.33 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9982", "type": "HCPCS" } ], "description": "flutemetamol f18 diagnostic", "standard_charges": [ { "billing_class": "facility", "maximum": 7488.0, "minimum": 1944.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1944.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7488.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7488.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2369.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2369.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9983", "type": "HCPCS" } ], "description": "florbetaben f18 diagnostic", "standard_charges": [ { "billing_class": "facility", "maximum": 7956.0, "minimum": 1584.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1584.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7956.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7956.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3451.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3451.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9991", "type": "HCPCS" } ], "description": "Buprenorph xr 100 mg or less", "standard_charges": [ { "billing_class": "facility", "maximum": 5235.21, "minimum": 2016.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2016.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4520.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4520.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3284.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5235.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5235.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9992", "type": "HCPCS" } ], "description": "Buprenorphine xr over 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5235.21, "minimum": 2016.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2016.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4520.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4520.44 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3284.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5235.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5235.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0012", "type": "HCPCS" } ], "description": "Butorphanal tartrate, nasal spray, 25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 149.89, "minimum": 131.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 131.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 131.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 149.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 149.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0014", "type": "HCPCS" } ], "description": "Tacrine HCl, 10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.26, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0017", "type": "HCPCS" } ], "description": "Injection, aminocaproic acid, 5mg", "standard_charges": [ { "billing_class": "facility", "maximum": 29.95, "minimum": 15.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 15.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0023", "type": "HCPCS" } ], "description": "Injection, cimetidine HCl, 300 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.26, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0028", "type": "HCPCS" } ], "description": "Injection, famotidine, 20mg", "standard_charges": [ { "billing_class": "facility", "maximum": 4.82, "minimum": 1.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0032", "type": "HCPCS" } ], "description": "Injection, nafcillin sodium, 2 g", "standard_charges": [ { "billing_class": "facility", "maximum": 73.63, "minimum": 30.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 30.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0039", "type": "HCPCS" } ], "description": "Injection, sulfamethoxazole and trimethoprim, 10 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 29.34, "minimum": 29.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 29.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89190", "type": "HCPCS" } ], "description": "Nasal smear for eosinophils", "standard_charges": [ { "billing_class": "facility", "maximum": 21.71, "minimum": 5.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89220", "type": "HCPCS" } ], "description": "Sputum specimen collection", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89230", "type": "HCPCS" } ], "description": "Collect sweat for test", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89240", "type": "HCPCS" } ], "description": "Pathology lab procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89250", "type": "HCPCS" } ], "description": "Cultr oocyte/embryo <4 days", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89251", "type": "HCPCS" } ], "description": "Cultr oocyte/embryo <4 days", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89253", "type": "HCPCS" } ], "description": "Embryo hatching", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89254", "type": "HCPCS" } ], "description": "Oocyte identification", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89255", "type": "HCPCS" } ], "description": "Prepare embryo for transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89257", "type": "HCPCS" } ], "description": "Sperm identification", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89258", "type": "HCPCS" } ], "description": "Cryopreservation embryo(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89259", "type": "HCPCS" } ], "description": "Cryopreservation sperm", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89260", "type": "HCPCS" } ], "description": "Sperm isolation simple", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89261", "type": "HCPCS" } ], "description": "Sperm isolation complex", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89264", "type": "HCPCS" } ], "description": "Identify sperm tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89268", "type": "HCPCS" } ], "description": "Insemination of oocytes", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89272", "type": "HCPCS" } ], "description": "Extended culture of oocytes", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89280", "type": "HCPCS" } ], "description": "Assist oocyte fertilization", "standard_charges": [ { "billing_class": "facility", "maximum": 2911.91, "minimum": 776.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2911.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2911.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89281", "type": "HCPCS" } ], "description": "Assist oocyte fertilization", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89290", "type": "HCPCS" } ], "description": "Biopsy oocyte polar body", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89291", "type": "HCPCS" } ], "description": "Biopsy oocyte polar body", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89300", "type": "HCPCS" } ], "description": "Semen analysis w/huhner", "standard_charges": [ { "billing_class": "facility", "maximum": 36.9, "minimum": 9.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89310", "type": "HCPCS" } ], "description": "Semen analysis w/count", "standard_charges": [ { "billing_class": "facility", "maximum": 32.29, "minimum": 8.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89320", "type": "HCPCS" } ], "description": "Semen anal vol/count/mot", "standard_charges": [ { "billing_class": "facility", "maximum": 46.16, "minimum": 12.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89321", "type": "HCPCS" } ], "description": "Semen anal sperm detection", "standard_charges": [ { "billing_class": "facility", "maximum": 45.19, "minimum": 12.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89322", "type": "HCPCS" } ], "description": "Semen anal strict criteria", "standard_charges": [ { "billing_class": "facility", "maximum": 58.13, "minimum": 15.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89325", "type": "HCPCS" } ], "description": "Sperm antibody test", "standard_charges": [ { "billing_class": "facility", "maximum": 40.01, "minimum": 10.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89329", "type": "HCPCS" } ], "description": "Sperm evaluation test", "standard_charges": [ { "billing_class": "facility", "maximum": 73.46, "minimum": 19.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89330", "type": "HCPCS" } ], "description": "Evaluation cervical mucus", "standard_charges": [ { "billing_class": "facility", "maximum": 38.93, "minimum": 10.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89331", "type": "HCPCS" } ], "description": "Retrograde ejaculation anal", "standard_charges": [ { "billing_class": "facility", "maximum": 73.46, "minimum": 19.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89335", "type": "HCPCS" } ], "description": "Cryopreserve testicular tiss", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89337", "type": "HCPCS" } ], "description": "Cryopreservation oocyte(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89342", "type": "HCPCS" } ], "description": "Storage/year embryo(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89343", "type": "HCPCS" } ], "description": "Storage/year sperm/semen", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89344", "type": "HCPCS" } ], "description": "Storage/year reprod tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89346", "type": "HCPCS" } ], "description": "Storage/year oocyte(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89352", "type": "HCPCS" } ], "description": "Thawing cryopresrved embryo", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89353", "type": "HCPCS" } ], "description": "Thawing cryopresrved sperm", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89354", "type": "HCPCS" } ], "description": "Thaw cryoprsvrd reprod tiss", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89356", "type": "HCPCS" } ], "description": "Thawing cryopresrved oocyte", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "89398", "type": "HCPCS" } ], "description": "Unlisted reprod med lab proc", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99000", "type": "HCPCS" } ], "description": "Specimen handling office-lab", "standard_charges": [ { "billing_class": "facility", "maximum": 20.33, "minimum": 20.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99001", "type": "HCPCS" } ], "description": "Specimen handling pt-lab", "standard_charges": [ { "billing_class": "facility", "maximum": 24.15, "minimum": 24.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0027", "type": "HCPCS" } ], "description": "Semen analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 24.38, "minimum": 6.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0103", "type": "HCPCS" } ], "description": "PSA Screening", "standard_charges": [ { "billing_class": "facility", "maximum": 72.41, "minimum": 19.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0123", "type": "HCPCS" } ], "description": "Screen cerv/vag thin layer", "standard_charges": [ { "billing_class": "facility", "maximum": 75.98, "minimum": 20.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0124", "type": "HCPCS" } ], "description": "Screen c/v thin layer by MD", "standard_charges": [ { "billing_class": "facility", "maximum": 86.4, "minimum": 86.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0141", "type": "HCPCS" } ], "description": "Scr c/v cyto,autosys and md", "standard_charges": [ { "billing_class": "facility", "maximum": 86.4, "minimum": 86.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0143", "type": "HCPCS" } ], "description": "Scr c/v cyto,thinlayer,rescr", "standard_charges": [ { "billing_class": "facility", "maximum": 101.44, "minimum": 27.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0144", "type": "HCPCS" } ], "description": "Scr c/v cyto,thinlayer,rescr", "standard_charges": [ { "billing_class": "facility", "maximum": 164.89, "minimum": 43.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 164.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 164.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0145", "type": "HCPCS" } ], "description": "Scr c/v cyto,thinlayer,rescr", "standard_charges": [ { "billing_class": "facility", "maximum": 99.34, "minimum": 26.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0147", "type": "HCPCS" } ], "description": "Scr c/v cyto, automated sys", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0148", "type": "HCPCS" } ], "description": "Scr c/v cyto, autosys, rescr", "standard_charges": [ { "billing_class": "facility", "maximum": 119.78, "minimum": 31.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 119.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 119.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0306", "type": "HCPCS" } ], "description": "CBC/diffwbc w/o platelet", "standard_charges": [ { "billing_class": "facility", "maximum": 29.14, "minimum": 7.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0307", "type": "HCPCS" } ], "description": "CBC without platelet", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0328", "type": "HCPCS" } ], "description": "Fecal blood scrn immunoassay", "standard_charges": [ { "billing_class": "facility", "maximum": 67.69, "minimum": 18.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0416", "type": "HCPCS" } ], "description": "Prostate biopsy, any mthd", "standard_charges": [ { "billing_class": "facility", "maximum": 1215.41, "minimum": 345.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1215.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1215.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0432", "type": "HCPCS" } ], "description": "EIA HIV-1/HIV-2 screen", "standard_charges": [ { "billing_class": "facility", "maximum": 73.39, "minimum": 19.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0433", "type": "HCPCS" } ], "description": "ELISA HIV-1/HIV-2 screen", "standard_charges": [ { "billing_class": "facility", "maximum": 68.59, "minimum": 18.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0435", "type": "HCPCS" } ], "description": "Oral hiv-1/hiv-2 screen", "standard_charges": [ { "billing_class": "facility", "maximum": 44.93, "minimum": 11.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0040", "type": "HCPCS" } ], "description": "Injection, ticarcillin disodium and clavulanate potassium, 3.1 g", "standard_charges": [ { "billing_class": "facility", "maximum": 28.05, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0074", "type": "HCPCS" } ], "description": "Injection, cefotetan disodium, 500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 28.03, "minimum": 28.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 28.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0078", "type": "HCPCS" } ], "description": "Injection, fosphenytoin sodium, 750 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 344.5, "minimum": 86.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 86.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 86.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 344.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 344.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0080", "type": "HCPCS" } ], "description": "Injection, pentamidine isethonate, 300 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 403.44, "minimum": 228.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 228.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 228.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 403.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 403.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0081", "type": "HCPCS" } ], "description": "Injection, piperacillin sodium, 500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.5, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0088", "type": "HCPCS" } ], "description": "Imatinib, 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 6.95, "minimum": 6.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0090", "type": "HCPCS" } ], "description": "Sildenafil citrate, 25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 152.93, "minimum": 0.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 152.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 152.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0091", "type": "HCPCS" } ], "description": "Granisetron HCl, 1mg (for circumstances falling under the Medicare Statute, use Q0166)", "standard_charges": [ { "billing_class": "facility", "maximum": 159.54, "minimum": 7.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 7.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 159.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 159.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0092", "type": "HCPCS" } ], "description": "Injection, hydromorphone HCl, 250 mg (loading dose for infusion pump)", "standard_charges": [ { "billing_class": "facility", "maximum": 202.49, "minimum": 195.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 195.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 195.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 202.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 202.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0093", "type": "HCPCS" } ], "description": "Injection, morphine sulfate, 500mg (loding dose for infusion pump)", "standard_charges": [ { "billing_class": "facility", "maximum": 465.47, "minimum": 18.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 465.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 465.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0104", "type": "HCPCS" } ], "description": "Zidovudine, oral, 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.77, "minimum": 3.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0106", "type": "HCPCS" } ], "description": "Buproprion HCl sustained release tablit, 150 mg, per bottle of 60 tablets", "standard_charges": [ { "billing_class": "facility", "maximum": 35.57, "minimum": 25.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 35.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0108", "type": "HCPCS" } ], "description": "Mercaptopuine, oral, 50 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 36.07, "minimum": 6.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 6.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 6.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0109", "type": "HCPCS" } ], "description": "Methadone, oral, 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.27, "minimum": 0.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0117", "type": "HCPCS" } ], "description": "Tretinoin, topical, 5 g", "standard_charges": [ { "billing_class": "facility", "maximum": 8.78, "minimum": 8.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 8.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0122", "type": "HCPCS" } ], "description": "Injection, menotropins, 75 IU", "standard_charges": [ { "billing_class": "facility", "maximum": 789.42, "minimum": 568.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 568.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 568.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 789.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 789.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0126", "type": "HCPCS" } ], "description": "Injection, follitropin alfa, 75 IU", "standard_charges": [ { "billing_class": "facility", "maximum": 660.05, "minimum": 565.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 565.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 565.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 660.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 660.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0128", "type": "HCPCS" } ], "description": "Injection, follitropin beta, 75 IU", "standard_charges": [ { "billing_class": "facility", "maximum": 707.31, "minimum": 508.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 508.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 508.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 707.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 707.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0132", "type": "HCPCS" } ], "description": "Injection, ganirelix acetate, 250 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 595.74, "minimum": 430.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 430.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 430.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 595.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 595.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0136", "type": "HCPCS" } ], "description": "Clozapine, 25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.75, "minimum": 1.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0137", "type": "HCPCS" } ], "description": "Didanosine (ddI), 25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 2.09, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0138", "type": "HCPCS" } ], "description": "Finasteride, 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 16.02, "minimum": 0.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0139", "type": "HCPCS" } ], "description": "Minoxidil, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.88, "minimum": 1.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0140", "type": "HCPCS" } ], "description": "Saquinavir, 200 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 3.5, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0145", "type": "HCPCS" } ], "description": "pegylated interferon alfa-2a, 180 mcg/ ml", "standard_charges": [ { "billing_class": "facility", "maximum": 3521.18, "minimum": 2605.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2605.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2605.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3521.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3521.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0148", "type": "HCPCS" } ], "description": "Peg interferon alfa-2B/10", "standard_charges": [ { "billing_class": "facility", "maximum": 0.02, "minimum": 0.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0155", "type": "HCPCS" } ], "description": "Sterile dilutant for epoprostenol, 50 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 33.93, "minimum": 33.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 33.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0156", "type": "HCPCS" } ], "description": "Exemestane, 25 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 52.03, "minimum": 3.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 3.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0157", "type": "HCPCS" } ], "description": "Becaplermin gel 0.01%, 0.5 gm", "standard_charges": [ { "billing_class": "facility", "maximum": 140.38, "minimum": 106.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 106.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 106.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 140.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0160", "type": "HCPCS" } ], "description": "Dextoamphetamine sulfate, 5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 14.17, "minimum": 1.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0169", "type": "HCPCS" } ], "description": "Calcitrol", "standard_charges": [ { "billing_class": "facility", "maximum": 2.63, "minimum": 0.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0170", "type": "HCPCS" } ], "description": "Anastrozole, oral, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 40.0, "minimum": 1.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0172", "type": "HCPCS" } ], "description": "Chlorambucil, oral, 2 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1878.25, "minimum": 618.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 618.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 618.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1878.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1878.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0174", "type": "HCPCS" } ], "description": "Dolasetron mesylate, oral 50 mg (for circumstances falling under the medicare statute, use q0180)", "standard_charges": [ { "billing_class": "facility", "maximum": 234.31, "minimum": 69.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 69.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 234.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 234.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0176", "type": "HCPCS" } ], "description": "Hydroxyurea, oral, 500 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 12.41, "minimum": 1.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0178", "type": "HCPCS" } ], "description": "Lomustine, oral, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 352.19, "minimum": 263.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 263.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 263.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 352.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 352.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0179", "type": "HCPCS" } ], "description": "Megestrol acetate, oral, 20 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.25, "minimum": 0.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0182", "type": "HCPCS" } ], "description": "Procarbazine HCl, oral, 50 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 482.98, "minimum": 302.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 302.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 302.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 482.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 482.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0183", "type": "HCPCS" } ], "description": "Prochlorperazine maleate, oral, 5 mg (for circumstances falling under the medicare statute, use q0164)", "standard_charges": [ { "billing_class": "facility", "maximum": 1.63, "minimum": 0.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0187", "type": "HCPCS" } ], "description": "Tamoxifen citrate, oral, 10 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 9.24, "minimum": 0.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0189", "type": "HCPCS" } ], "description": "testosterone pellet, 75 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 351.81, "minimum": 246.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 246.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 246.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 351.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 351.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0190", "type": "HCPCS" } ], "description": "Mitepristone, oral, 200 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 139.57, "minimum": 100.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 100.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 100.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 139.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 139.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0191", "type": "HCPCS" } ], "description": "Misoprostol, oral, 200 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 7.67, "minimum": 2.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 2.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 2.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0194", "type": "HCPCS" } ], "description": "Dialysis/stress vitamin supplement, oral, 100 capsules", "standard_charges": [ { "billing_class": "facility", "maximum": 23.05, "minimum": 23.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 23.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S4991", "type": "HCPCS" } ], "description": "Nicotine patch nonlegend", "standard_charges": [ { "billing_class": "facility", "maximum": 4.17, "minimum": 4.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 4.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 4.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S4993", "type": "HCPCS" } ], "description": "Contraceptive pills for bc", "standard_charges": [ { "billing_class": "facility", "maximum": 1.85, "minimum": 1.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5010", "type": "HCPCS" } ], "description": "5% dextrose and 0.45% saline", "standard_charges": [ { "billing_class": "facility", "maximum": 18.49, "minimum": 18.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 18.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5012", "type": "HCPCS" } ], "description": "5% dextrose with potassium", "standard_charges": [ { "billing_class": "facility", "maximum": 11.12, "minimum": 11.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 11.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5550", "type": "HCPCS" } ], "description": "Insulin rapid 5 u", "standard_charges": [ { "billing_class": "facility", "maximum": 1.3, "minimum": 0.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5551", "type": "HCPCS" } ], "description": "Insulin most rapid 5 u", "standard_charges": [ { "billing_class": "facility", "maximum": 1.03, "minimum": 1.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5552", "type": "HCPCS" } ], "description": "Insulin intermed 5 u", "standard_charges": [ { "billing_class": "facility", "maximum": 0.76, "minimum": 0.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 0.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5553", "type": "HCPCS" } ], "description": "Insulin long acting 5 u", "standard_charges": [ { "billing_class": "facility", "maximum": 1.33, "minimum": 1.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 1.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 1.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5566", "type": "HCPCS" } ], "description": "Insulin cartridge 300 u", "standard_charges": [ { "billing_class": "facility", "maximum": 62.88, "minimum": 62.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 62.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 62.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5570", "type": "HCPCS" } ], "description": "Insulin dispos pen 1.5 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 234.0, "minimum": 234.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 234.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 234.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S5571", "type": "HCPCS" } ], "description": "Insulin dispos pen 3 ml", "standard_charges": [ { "billing_class": "facility", "maximum": 74.46, "minimum": 74.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 74.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_dollar": 74.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0452", "type": "HCPCS" } ], "description": "Molecular pathology interpr", "standard_charges": [ { "billing_class": "facility", "maximum": 11.44, "minimum": 11.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0472", "type": "HCPCS" } ], "description": "Hep c screen high risk/other", "standard_charges": [ { "billing_class": "facility", "maximum": 173.81, "minimum": 46.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 173.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 173.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0475", "type": "HCPCS" } ], "description": "Hiv combination assay", "standard_charges": [ { "billing_class": "facility", "maximum": 90.3, "minimum": 24.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0476", "type": "HCPCS" } ], "description": "Hpv combo assay ca screen", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "description": "Drug test def 1-7 classes", "standard_charges": [ { "billing_class": "facility", "maximum": 429.11, "minimum": 114.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 429.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 429.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0481", "type": "HCPCS" } ], "description": "Drug test def 8-14 classes", "standard_charges": [ { "billing_class": "facility", "maximum": 587.21, "minimum": 156.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 587.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 587.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0482", "type": "HCPCS" } ], "description": "Drug test def 15-21 classes", "standard_charges": [ { "billing_class": "facility", "maximum": 745.28, "minimum": 198.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 198.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 745.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 745.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0483", "type": "HCPCS" } ], "description": "Drug test def 22+ classes", "standard_charges": [ { "billing_class": "facility", "maximum": 925.95, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 925.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 925.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0499", "type": "HCPCS" } ], "description": "Hepb screen high risk indiv", "standard_charges": [ { "billing_class": "facility", "maximum": 106.01, "minimum": 28.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 106.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0659", "type": "HCPCS" } ], "description": "Drug test def simple all cl", "standard_charges": [ { "billing_class": "facility", "maximum": 233.03, "minimum": 62.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 233.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 233.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G9143", "type": "HCPCS" } ], "description": "Warfarin respon genetic test", "standard_charges": [ { "billing_class": "facility", "maximum": 452.7, "minimum": 452.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 452.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 452.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P2028", "type": "HCPCS" } ], "description": "Cephalin floculation test", "standard_charges": [ { "billing_class": "facility", "maximum": 18.56, "minimum": 4.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P2029", "type": "HCPCS" } ], "description": "Congo red blood test", "standard_charges": [ { "billing_class": "facility", "maximum": 18.56, "minimum": 4.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P2031", "type": "HCPCS" } ], "description": "Hair analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 18.56, "minimum": 18.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P2033", "type": "HCPCS" } ], "description": "Blood thymol turbidity", "standard_charges": [ { "billing_class": "facility", "maximum": 18.56, "minimum": 4.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P2038", "type": "HCPCS" } ], "description": "Blood mucoprotein", "standard_charges": [ { "billing_class": "facility", "maximum": 18.56, "minimum": 4.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P3000", "type": "HCPCS" } ], "description": "Screen pap by tech w md supv", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P3001", "type": "HCPCS" } ], "description": "Screening pap smear by phys", "standard_charges": [ { "billing_class": "facility", "maximum": 86.4, "minimum": 86.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P7001", "type": "HCPCS" } ], "description": "Culture bacterial urine", "standard_charges": [ { "billing_class": "facility", "maximum": 68.63, "minimum": 68.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9100", "type": "HCPCS" } ], "description": "Pathogen test for platelets", "standard_charges": [ { "billing_class": "facility", "maximum": 215.55, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 215.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 215.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9612", "type": "HCPCS" } ], "description": "Catheterize for urine spec", "standard_charges": [ { "billing_class": "facility", "maximum": 32.14, "minimum": 9.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9615", "type": "HCPCS" } ], "description": "Urine specimen collect mult", "standard_charges": [ { "billing_class": "facility", "maximum": 32.14, "minimum": 32.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0091", "type": "HCPCS" } ], "description": "Obtaining screen pap smear", "standard_charges": [ { "billing_class": "facility", "maximum": 93.6, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0111", "type": "HCPCS" } ], "description": "Wet mounts/ w preparations", "standard_charges": [ { "billing_class": "facility", "maximum": 64.91, "minimum": 18.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0112", "type": "HCPCS" } ], "description": "Potassium hydroxide preps", "standard_charges": [ { "billing_class": "facility", "maximum": 21.86, "minimum": 5.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0113", "type": "HCPCS" } ], "description": "Pinworm examinations", "standard_charges": [ { "billing_class": "facility", "maximum": 16.01, "minimum": 4.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0114", "type": "HCPCS" } ], "description": "Fern test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.53, "minimum": 9.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0115", "type": "HCPCS" } ], "description": "Post-coital mucous exam", "standard_charges": [ { "billing_class": "facility", "maximum": 93.75, "minimum": 25.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "U0001", "type": "HCPCS" } ], "description": "2019 nCoV diagnostic P", "standard_charges": [ { "billing_class": "facility", "maximum": 134.7, "minimum": 35.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 134.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 134.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "U0002", "type": "HCPCS" } ], "description": "COVID-19 lab test non-CDC", "standard_charges": [ { "billing_class": "facility", "maximum": 192.41, "minimum": 51.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90399", "type": "HCPCS" } ], "description": "Immune globulin", "standard_charges": [ { "billing_class": "facility", "maximum": 1159.58, "minimum": 1159.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1159.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1159.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90634", "type": "HCPCS" } ], "description": "Hepa vacc ped/adol 3 dose", "standard_charges": [ { "billing_class": "facility", "maximum": 78.89, "minimum": 78.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90676", "type": "HCPCS" } ], "description": "Rabies vaccine id", "standard_charges": [ { "billing_class": "facility", "maximum": 716.71, "minimum": 236.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 236.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 716.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 716.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96360", "type": "HCPCS" } ], "description": "Hydration iv infusion init", "standard_charges": [ { "billing_class": "facility", "maximum": 570.97, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 570.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 570.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96361", "type": "HCPCS" } ], "description": "Hydrate iv infusion add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 125.04, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 125.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 125.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2001", "type": "HCPCS" } ], "description": "Miscellaneous M >=66.50", "standard_charges": [ { "billing_class": "facility", "maximum": 2984.79, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2984.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2984.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2002", "type": "HCPCS" } ], "description": "Miscellaneous M >=55.50 and M <66.50", "standard_charges": [ { "billing_class": "facility", "maximum": 471.59, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 471.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 471.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2004", "type": "HCPCS" } ], "description": "Miscellaneous M <46.50 and A >=77.50", "standard_charges": [ { "billing_class": "facility", "maximum": 42.28, "minimum": 42.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2005", "type": "HCPCS" } ], "description": "Miscellaneous M <46.50 and A <77.50", "standard_charges": [ { "billing_class": "facility", "maximum": 689.88, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 689.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 689.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2007", "type": "HCPCS" } ], "description": "Restrata, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 218.26, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 218.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 218.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2008", "type": "HCPCS" } ], "description": "Theragenesis, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 243.68, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 243.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 243.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2009", "type": "HCPCS" } ], "description": "Symphony, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 339.21, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 339.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 339.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2013", "type": "HCPCS" } ], "description": "Innovamatrix fs, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3329.29, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3329.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3329.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2014", "type": "HCPCS" } ], "description": "Omeza collag per 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 193.09, "minimum": 193.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 193.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 193.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2015", "type": "HCPCS" } ], "description": "Phoenix wnd mtrx, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3898.77, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3898.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3898.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2019", "type": "HCPCS" } ], "description": "Kerecis marigen shld sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1851.69, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1851.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1851.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2021", "type": "HCPCS" } ], "description": "Neomatrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3634.35, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3634.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3634.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2022", "type": "HCPCS" } ], "description": "Innovabrn/innovamatx xl sqcm", "standard_charges": [ { "billing_class": "facility", "maximum": 3506.36, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3506.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3506.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2023", "type": "HCPCS" } ], "description": "Innovamatrix pd, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 40.32, "minimum": 40.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2024", "type": "HCPCS" } ], "description": "Resolve matrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5259.54, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5259.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5259.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A2025", "type": "HCPCS" } ], "description": "Miro3d per cubic cm", "standard_charges": [ { "billing_class": "facility", "maximum": 674.09, "minimum": 674.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 674.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 674.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A4596", "type": "HCPCS" } ], "description": "Ces system monthly supp", "standard_charges": [ { "billing_class": "facility", "maximum": 103.44, "minimum": 103.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 103.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 103.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A4642", "type": "HCPCS" } ], "description": "In111 satumomab", "standard_charges": [ { "billing_class": "facility", "maximum": 4399.6, "minimum": 4399.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4399.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4399.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9500", "type": "HCPCS" } ], "description": "Tc99m sestamibi", "standard_charges": [ { "billing_class": "facility", "maximum": 1221.07, "minimum": 1221.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1221.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1221.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9504", "type": "HCPCS" } ], "description": "Tc99m apcitide", "standard_charges": [ { "billing_class": "facility", "maximum": 1379.74, "minimum": 1379.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1379.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1379.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9517", "type": "HCPCS" } ], "description": "I131 iodide cap, rx", "standard_charges": [ { "billing_class": "facility", "maximum": 62.68, "minimum": 24.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9524", "type": "HCPCS" } ], "description": "I131 serum albumin, dx", "standard_charges": [ { "billing_class": "facility", "maximum": 976.52, "minimum": 976.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 976.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 976.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9527", "type": "HCPCS" } ], "description": "Iodine I-125 sodium iodide", "standard_charges": [ { "billing_class": "facility", "maximum": 565.25, "minimum": 396.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 396.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 565.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 565.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9528", "type": "HCPCS" } ], "description": "Iodine i-131 iodide cap, dx", "standard_charges": [ { "billing_class": "facility", "maximum": 255.96, "minimum": 255.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 255.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 255.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9530", "type": "HCPCS" } ], "description": "I131 iodide sol, rx", "standard_charges": [ { "billing_class": "facility", "maximum": 56.58, "minimum": 20.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9531", "type": "HCPCS" } ], "description": "I131 max 100uci", "standard_charges": [ { "billing_class": "facility", "maximum": 11.41, "minimum": 11.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9532", "type": "HCPCS" } ], "description": "I125 serum albumin, dx", "standard_charges": [ { "billing_class": "facility", "maximum": 555.77, "minimum": 469.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 469.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 555.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 555.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9536", "type": "HCPCS" } ], "description": "Tc99m depreotide", "standard_charges": [ { "billing_class": "facility", "maximum": 2101.2, "minimum": 2101.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2101.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2101.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9546", "type": "HCPCS" } ], "description": "Co57/58", "standard_charges": [ { "billing_class": "facility", "maximum": 3.5, "minimum": 3.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9551", "type": "HCPCS" } ], "description": "Tc99m succimer", "standard_charges": [ { "billing_class": "facility", "maximum": 1594.51, "minimum": 659.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 659.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1594.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1594.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9552", "type": "HCPCS" } ], "description": "F18 fdg", "standard_charges": [ { "billing_class": "facility", "maximum": 1131.67, "minimum": 1131.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1131.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1131.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9555", "type": "HCPCS" } ], "description": "Rb82 rubidium", "standard_charges": [ { "billing_class": "facility", "maximum": 1225.46, "minimum": 1225.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1225.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1225.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9561", "type": "HCPCS" } ], "description": "Tc99m oxidronate", "standard_charges": [ { "billing_class": "facility", "maximum": 136.75, "minimum": 136.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 136.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 136.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9562", "type": "HCPCS" } ], "description": "Tc99m mertiatide", "standard_charges": [ { "billing_class": "facility", "maximum": 2081.9, "minimum": 2081.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2081.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2081.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9564", "type": "HCPCS" } ], "description": "P32 chromic phosphate", "standard_charges": [ { "billing_class": "facility", "maximum": 410.24, "minimum": 410.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 410.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 410.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9567", "type": "HCPCS" } ], "description": "Technetium tc-99m aerosol", "standard_charges": [ { "billing_class": "facility", "maximum": 55.23, "minimum": 55.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9572", "type": "HCPCS" } ], "description": "Indium In-111 pentetreotide", "standard_charges": [ { "billing_class": "facility", "maximum": 5188.59, "minimum": 2000.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2000.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5188.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5188.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9580", "type": "HCPCS" } ], "description": "Sodium fluoride F-18", "standard_charges": [ { "billing_class": "facility", "maximum": 710.05, "minimum": 710.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 710.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 710.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9697", "type": "HCPCS" } ], "description": "Inj, magtrace per study dose", "standard_charges": [ { "billing_class": "facility", "maximum": 3083.87, "minimum": 1254.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1254.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3083.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3083.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A9699", "type": "HCPCS" } ], "description": "Radiopharm rx agent noc", "standard_charges": [ { "billing_class": "facility", "maximum": 122549.05, "minimum": 122549.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 122549.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 122549.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9250", "type": "HCPCS" } ], "description": "Artiss fibrin sealant", "standard_charges": [ { "billing_class": "facility", "maximum": 364.5, "minimum": 141.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 141.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 364.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 364.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0139", "type": "HCPCS" } ], "description": "Inj, adalimumab, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 248.59, "minimum": 248.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 248.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 248.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0209", "type": "HCPCS" } ], "description": "Inj, sod thiosulfate (hope)", "standard_charges": [ { "billing_class": "facility", "maximum": 2.52, "minimum": 0.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0211", "type": "HCPCS" } ], "description": "Inj, nithiodote, 3mg / 125mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5.88, "minimum": 2.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0216", "type": "HCPCS" } ], "description": "Inj, alfentanil hcl, 500mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 12.25, "minimum": 12.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0380", "type": "HCPCS" } ], "description": "Inj metaraminol bitartrate", "standard_charges": [ { "billing_class": "facility", "maximum": 2.63, "minimum": 2.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0572", "type": "HCPCS" } ], "description": "Bupren/nal up to 3mg bupreno", "standard_charges": [ { "billing_class": "facility", "maximum": 19.35, "minimum": 19.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0573", "type": "HCPCS" } ], "description": "Bupren/nal 3.1 to 6mg bupren", "standard_charges": [ { "billing_class": "facility", "maximum": 30.6, "minimum": 30.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0574", "type": "HCPCS" } ], "description": "Bupren/nal 6.1 to 10mg bupre", "standard_charges": [ { "billing_class": "facility", "maximum": 31.33, "minimum": 31.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0575", "type": "HCPCS" } ], "description": "Bupren/nal over 10mg bupreno", "standard_charges": [ { "billing_class": "facility", "maximum": 50.14, "minimum": 50.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0714T", "type": "HCPCS" } ], "description": "Tprnl lsr ablt b9 prst8 hypr", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0717T", "type": "HCPCS" } ], "description": "Adrc ther prtl rc tear", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0718T", "type": "HCPCS" } ], "description": "Adrc ther prtl rc tear njx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0719T", "type": "HCPCS" } ], "description": "Pst vrt jt rplcmt lmbr 1 sgm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0720T", "type": "HCPCS" } ], "description": "Prq elc nrv stim cn wo implt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0725T", "type": "HCPCS" } ], "description": "Vestibular dev impltj uni", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0726T", "type": "HCPCS" } ], "description": "Rmvl implt vstibular dev uni", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0727T", "type": "HCPCS" } ], "description": "Rmvl&rplcmt implt vstblr dev", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0730T", "type": "HCPCS" } ], "description": "Trabeculotomy lsr w/oct gdn", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0736T", "type": "HCPCS" } ], "description": "Colonic lavage 35+l water", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0737T", "type": "HCPCS" } ], "description": "Xenograft impltj artclr surf", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0744T", "type": "HCPCS" } ], "description": "Insj bioprostc vlv fem vn", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0780T", "type": "HCPCS" } ], "description": "Instlj fecal microbiota ssp", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0781T", "type": "HCPCS" } ], "description": "Brnchsc rf dstrj pulm nrv bi", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0782T", "type": "HCPCS" } ], "description": "Brnchsc rf dstrj plm nrv uni", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10005", "type": "HCPCS" } ], "description": "Fna bx w/us gdn 1st les", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10007", "type": "HCPCS" } ], "description": "Fna bx w/fluor gdn 1st les", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10009", "type": "HCPCS" } ], "description": "Fna bx w/ct gdn 1st les", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10011", "type": "HCPCS" } ], "description": "Fna bx w/mr gdn 1st les", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10021", "type": "HCPCS" } ], "description": "Fna w/o image", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10030", "type": "HCPCS" } ], "description": "Guide cathet fluid drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10035", "type": "HCPCS" } ], "description": "Perq dev soft tiss 1st imag", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10040", "type": "HCPCS" } ], "description": "Acne surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10060", "type": "HCPCS" } ], "description": "Drainage of skin abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10061", "type": "HCPCS" } ], "description": "Drainage of skin abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10080", "type": "HCPCS" } ], "description": "Drainage of pilonidal cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10081", "type": "HCPCS" } ], "description": "Drainage of pilonidal cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10120", "type": "HCPCS" } ], "description": "Remove foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10121", "type": "HCPCS" } ], "description": "Remove foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10140", "type": "HCPCS" } ], "description": "Drainage of hematoma/fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10160", "type": "HCPCS" } ], "description": "Puncture drainage of lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "10180", "type": "HCPCS" } ], "description": "Complex drainage wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11000", "type": "HCPCS" } ], "description": "Debride infected skin", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0707T", "type": "HCPCS" } ], "description": "Njx b1 sub mtrl sbchdrl dfct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0699T", "type": "HCPCS" } ], "description": "Njx pst chmbr eye medication", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0686T", "type": "HCPCS" } ], "description": "Histotripsy mal hepatcel tis", "standard_charges": [ { "billing_class": "facility", "maximum": 33032.77, "minimum": 26701.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33032.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0682T", "type": "HCPCS" } ], "description": "Removal pulse gen only isdss", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0681T", "type": "HCPCS" } ], "description": "Rlcj pulse gen only isdss", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0680T", "type": "HCPCS" } ], "description": "Insj/rplcmt pg only isdss", "standard_charges": [ { "billing_class": "facility", "maximum": 18706.01, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18706.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0679T", "type": "HCPCS" } ], "description": "Laps rmvl lead isdss", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0678T", "type": "HCPCS" } ], "description": "Laps repos lead isdss ea add", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0677T", "type": "HCPCS" } ], "description": "Laps repos lead isdss 1st ld", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0676T", "type": "HCPCS" } ], "description": "Laps insj nw/rpcmt isdss ea", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0675T", "type": "HCPCS" } ], "description": "Laps insj nw/rpcmt isdss 1ld", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0674T", "type": "HCPCS" } ], "description": "Laps insj nw/rpcmt prm isdss", "standard_charges": [ { "billing_class": "facility", "maximum": 29753.66, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0673T", "type": "HCPCS" } ], "description": "Abltj b9 thyr ndul perq lasr", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0672T", "type": "HCPCS" } ], "description": "Ndovag cryg rf remdl tiss", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0671T", "type": "HCPCS" } ], "description": "Insj ant sgm aq drg dev 1+", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0670T", "type": "HCPCS" } ], "description": "Bkbench rcnstj don uter artl", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0669T", "type": "HCPCS" } ], "description": "Bkbench rcnstj don uter ven", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0668T", "type": "HCPCS" } ], "description": "Bkbench prep don uter algrft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0667T", "type": "HCPCS" } ], "description": "Don hysterectomy rcp uter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0666T", "type": "HCPCS" } ], "description": "Don hysterectomy laps liv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0665T", "type": "HCPCS" } ], "description": "Don hysterectomy open liv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0664T", "type": "HCPCS" } ], "description": "Don hysterectomy open cdvr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0661T", "type": "HCPCS" } ], "description": "Rmvl&Rimpltj ant sgm implt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0660T", "type": "HCPCS" } ], "description": "Implt ant sgm io nbio rx sys", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0659T", "type": "HCPCS" } ], "description": "Tcat intra-c nfs supersat o2", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0657T", "type": "HCPCS" } ], "description": "Vrt bdy tethering ant 8+ seg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0656T", "type": "HCPCS" } ], "description": "Vrt bdy tethering ant", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0655T", "type": "HCPCS" } ], "description": "Tprnl focal abltj mal prst8", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0654T", "type": "HCPCS" } ], "description": "Egd flx transnasal tube/cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0653T", "type": "HCPCS" } ], "description": "Egd flx transnasal bx 1/ml", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0652T", "type": "HCPCS" } ], "description": "Egd flx transnasal dx br/wa", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0647T", "type": "HCPCS" } ], "description": "Insj gtube perq mag gastrpxy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0646T", "type": "HCPCS" } ], "description": "Ttvi/rplcmt w/prstc vlv perq", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0645T", "type": "HCPCS" } ], "description": "Tcat impltj c sins rdctj dev", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0644T", "type": "HCPCS" } ], "description": "Tcat rmvl/dblk icar mas perq", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0643T", "type": "HCPCS" } ], "description": "Tcat l ventr rstrj dev implt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0632T", "type": "HCPCS" } ], "description": "Perq tcat us abltj nrv p-art", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0629T", "type": "HCPCS" } ], "description": "Perq njx algc ct lmbr 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0627T", "type": "HCPCS" } ], "description": "Perq njx algc fluor lmbr 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0622T", "type": "HCPCS" } ], "description": "Trabeculostomy int lsr w/scp", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0621T", "type": "HCPCS" } ], "description": "Trabeculostomy interno laser", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0620T", "type": "HCPCS" } ], "description": "Evasc ven artlz tibl/prnl vn", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 42470.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42470.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0619T", "type": "HCPCS" } ], "description": "Cysto w/prst8 commissurotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0618T", "type": "HCPCS" } ], "description": "Insj iris prosth sec io lens", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0617T", "type": "HCPCS" } ], "description": "Insj iris prosth w/rmvl&insj", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0616T", "type": "HCPCS" } ], "description": "Insertion of iris prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0614T", "type": "HCPCS" } ], "description": "Rmvl&rplcmt ss impl dfb pg", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0613T", "type": "HCPCS" } ], "description": "Perq tcat intratrl septl sht", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J0945", "type": "HCPCS" } ], "description": "Brompheniramine maleate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1105", "type": "HCPCS" } ], "description": "Dexmedetomidine film, 1 mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.76, "minimum": 1.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0601T", "type": "HCPCS" } ], "description": "Ire abltj 1+tumors open", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0600T", "type": "HCPCS" } ], "description": "Ire abltj 1+tum organ perq", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0597T", "type": "HCPCS" } ], "description": "Temp fml iu valve-pmp rplcmt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0596T", "type": "HCPCS" } ], "description": "Temp fml iu vlv-pmp 1st insj", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0594T", "type": "HCPCS" } ], "description": "Osteot hum xtrnl lngth dev", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0588T", "type": "HCPCS" } ], "description": "Revision/removal isdns ptn", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0587T", "type": "HCPCS" } ], "description": "Perq impltj/rplcmt isdns ptn", "standard_charges": [ { "billing_class": "facility", "maximum": 6144.98, "minimum": 3714.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6144.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0586T", "type": "HCPCS" } ], "description": "Open islet cell transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0585T", "type": "HCPCS" } ], "description": "Laps islet cell transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0584T", "type": "HCPCS" } ], "description": "Perq islet cell transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0583T", "type": "HCPCS" } ], "description": "Tmpst auto tube dlvr sys", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0582T", "type": "HCPCS" } ], "description": "Trurl abltj mal prst8 tiss", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 12721.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12721.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0581T", "type": "HCPCS" } ], "description": "Abltj mal brst tum perq crtx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0580T", "type": "HCPCS" } ], "description": "Rmvl ss impl dfb pg only", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0574T", "type": "HCPCS" } ], "description": "Repos prev ss impl dfb eltrd", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0573T", "type": "HCPCS" } ], "description": "Removal ss dfb electrode", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0572T", "type": "HCPCS" } ], "description": "Insertion ss dfb electrode", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0571T", "type": "HCPCS" } ], "description": "Insj/rplcmt icds ss eltrd", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 30265.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30265.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0570T", "type": "HCPCS" } ], "description": "Ttvr perq ea addl prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0569T", "type": "HCPCS" } ], "description": "Ttvr perq appr 1st prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0568T", "type": "HCPCS" } ], "description": "Intro mix saline&air f/ssg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0567T", "type": "HCPCS" } ], "description": "Perm flp tube occls w/implt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0566T", "type": "HCPCS" } ], "description": "Autol cell implt adps njx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0565T", "type": "HCPCS" } ], "description": "Autol cell implt adps hrvg", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0563T", "type": "HCPCS" } ], "description": "Evac meibomian glnd heat bi", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0553T", "type": "HCPCS" } ], "description": "Perq tcat iliac anast implt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0547T", "type": "HCPCS" } ], "description": "B1 matrl qual tst mcrind tib", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0545T", "type": "HCPCS" } ], "description": "Tcat tv annulus rcnstj", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0544T", "type": "HCPCS" } ], "description": "Tcat mv annulus rcnstj", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0543T", "type": "HCPCS" } ], "description": "Ta mv rpr w/artif chord tend", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0540T", "type": "HCPCS" } ], "description": "Car-t cll admn autologous", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0539T", "type": "HCPCS" } ], "description": "Receipt&prep car-t cll admn", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0538T", "type": "HCPCS" } ], "description": "Bld drv t lymphcyt prep trns", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0537T", "type": "HCPCS" } ], "description": "Bld drv t lymphcyt car-t cll", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0532T", "type": "HCPCS" } ], "description": "Removal iims implt mntr only", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0531T", "type": "HCPCS" } ], "description": "Removal iims electrode only", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0530T", "type": "HCPCS" } ], "description": "Removal complete iims", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0527T", "type": "HCPCS" } ], "description": "Insj/rplcmt iims implt mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0526T", "type": "HCPCS" } ], "description": "Insj/rplcmt iims eltrd only", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0525T", "type": "HCPCS" } ], "description": "Insj/rplcmt compl iims", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0524T", "type": "HCPCS" } ], "description": "Ev cath dir chem abltj w/img", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0520T", "type": "HCPCS" } ], "description": "Rmvl&rplcmt pg wcs new eltrd", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0519T", "type": "HCPCS" } ], "description": "Rmvl & rplcmt pg compnt wcs", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0518T", "type": "HCPCS" } ], "description": "Rmvl pg compnt wcs", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0517T", "type": "HCPCS" } ], "description": "Insj wcs lv pg compnt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0516T", "type": "HCPCS" } ], "description": "Insj wcs lv eltrd only", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0515T", "type": "HCPCS" } ], "description": "Insj wcs lv compl sys", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0512T", "type": "HCPCS" } ], "description": "Esw integ wnd hlg 1st wnd", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0511T", "type": "HCPCS" } ], "description": "Rmvl&rinsj sinus tarsi implt", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0510T", "type": "HCPCS" } ], "description": "Rmvl sinus tarsi implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0505T", "type": "HCPCS" } ], "description": "Ev fempop artl revsc", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0496T", "type": "HCPCS" } ], "description": "Mntr cdvr don lng ea addl hr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0495T", "type": "HCPCS" } ], "description": "Mntr cdvr don lng 1st 2 hrs", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0494T", "type": "HCPCS" } ], "description": "Prep & cannulj cdvr don lung", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0490T", "type": "HCPCS" } ], "description": "Regn cell tx scldr h mlt inj", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0489T", "type": "HCPCS" } ], "description": "Regn cell tx scldr hands", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0484T", "type": "HCPCS" } ], "description": "Tmvi transthoracic exposure", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0483T", "type": "HCPCS" } ], "description": "Tmvi percutaneous approach", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0481T", "type": "HCPCS" } ], "description": "Njx autol wbc concentrate", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0479T", "type": "HCPCS" } ], "description": "Fxjl abl lsr 1st 100 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0474T", "type": "HCPCS" } ], "description": "Insj aqueous drg dev io rsvr", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0449T", "type": "HCPCS" } ], "description": "Insj aqueous drain dev 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0448T", "type": "HCPCS" } ], "description": "Remvl insj impltbl gluc sens", "standard_charges": [ { "billing_class": "facility", "maximum": 4011.54, "minimum": 3714.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4011.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0447T", "type": "HCPCS" } ], "description": "Rmvl impltbl glucose sensor", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0446T", "type": "HCPCS" } ], "description": "Insj impltbl glucose sensor", "standard_charges": [ { "billing_class": "facility", "maximum": 4011.54, "minimum": 3714.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4011.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0442T", "type": "HCPCS" } ], "description": "Abltj perc plex/trncl nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0441T", "type": "HCPCS" } ], "description": "Abltj perc lxtr/perph nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0440T", "type": "HCPCS" } ], "description": "Abltj perc uxtr/perph nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0421T", "type": "HCPCS" } ], "description": "Waterjet prostate abltj cmpl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0420T", "type": "HCPCS" } ], "description": "Dstrj neurofibroma xtnsv", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0419T", "type": "HCPCS" } ], "description": "Dstrj neurofibroma xtnsv", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0416T", "type": "HCPCS" } ], "description": "Reloc skin pocket pls gen", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0415T", "type": "HCPCS" } ], "description": "Repos car modulj tranvns elt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0414T", "type": "HCPCS" } ], "description": "Rmvl & rpl car modulj pls gn", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0413T", "type": "HCPCS" } ], "description": "Rmvl car modulj tranvns elt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0412T", "type": "HCPCS" } ], "description": "Rmvl cardiac modulj pls gen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0411T", "type": "HCPCS" } ], "description": "Insj/rplc car modulj vnt elt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0410T", "type": "HCPCS" } ], "description": "Insj/rplc car modulj atr elt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0409T", "type": "HCPCS" } ], "description": "Insj/rplc car modulj pls gn", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0408T", "type": "HCPCS" } ], "description": "Insj/rplc cardiac modulj sys", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 30265.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30265.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0402T", "type": "HCPCS" } ], "description": "Collagen crosslinking cornea", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0398T", "type": "HCPCS" } ], "description": "Mrgfus strtctc les abltj", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0347T", "type": "HCPCS" } ], "description": "Ins bone device for rsa", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0345T", "type": "HCPCS" } ], "description": "Transcath mtral vlve repair", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0342T", "type": "HCPCS" } ], "description": "Thxp apheresis w/hdl delip", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4199.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4199.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0339T", "type": "HCPCS" } ], "description": "Trnscth renal symp denrv bil", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0338T", "type": "HCPCS" } ], "description": "Trnscth renal symp denrv unl", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0335T", "type": "HCPCS" } ], "description": "Extraosseous joint stblztion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0308T", "type": "HCPCS" } ], "description": "Insj ocular telescope prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 15871.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15871.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0278T", "type": "HCPCS" } ], "description": "Tempr", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0275T", "type": "HCPCS" } ], "description": "Perq lamot/lam lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0274T", "type": "HCPCS" } ], "description": "Perq lamot/lam crv/thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0273T", "type": "HCPCS" } ], "description": "Interrogate crtd sns w/pgrmg", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0272T", "type": "HCPCS" } ], "description": "Interrogate crtd sns dev", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0271T", "type": "HCPCS" } ], "description": "Rev/remvl crtd sns dev gen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0270T", "type": "HCPCS" } ], "description": "Rev/remvl crtd sns dev lead", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0269T", "type": "HCPCS" } ], "description": "Rev/remvl crtd sns dev total", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0268T", "type": "HCPCS" } ], "description": "Implt/rpl crtd sns dev gen", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0267T", "type": "HCPCS" } ], "description": "Implt/rpl crtd sns dev lead", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0266T", "type": "HCPCS" } ], "description": "Implt/rpl crtd sns dev total", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0265T", "type": "HCPCS" } ], "description": "Im b1 mrw cel ther hrvst onl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4199.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4199.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0264T", "type": "HCPCS" } ], "description": "Im b1 mrw cel ther xcl hrvst", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4199.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4199.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0263T", "type": "HCPCS" } ], "description": "Im b1 mrw cel ther cmpl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4199.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4199.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0253T", "type": "HCPCS" } ], "description": "Insert aqueous drain device", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0238T", "type": "HCPCS" } ], "description": "Trluml perip athrc iliac art", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0237T", "type": "HCPCS" } ], "description": "Trluml perip athrc brchiocph", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0236T", "type": "HCPCS" } ], "description": "Trluml perip athrc abd aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0235T", "type": "HCPCS" } ], "description": "Trluml perip athrc visceral", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0234T", "type": "HCPCS" } ], "description": "Trluml perip athrc renal art", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0232T", "type": "HCPCS" } ], "description": "Njx platelet plasma", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0221T", "type": "HCPCS" } ], "description": "Plmt post facet implt lumb", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0220T", "type": "HCPCS" } ], "description": "Plmt post facet implt thor", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0207T", "type": "HCPCS" } ], "description": "Clear eyelid gland w/heat", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0202T", "type": "HCPCS" } ], "description": "Post vert arthrplst 1 lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0201T", "type": "HCPCS" } ], "description": "Perq sacral augmt bilat inj", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0200T", "type": "HCPCS" } ], "description": "Perq sacral augmt unilat inj", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0184T", "type": "HCPCS" } ], "description": "Exc rectal tumor endoscopic", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0165T", "type": "HCPCS" } ], "description": "Revise Lumb Artif Disc Addl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0164T", "type": "HCPCS" } ], "description": "Remove Lumb Artif Disc Addl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0102T", "type": "HCPCS" } ], "description": "Extracorp shockwv tx anesth", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0101T", "type": "HCPCS" } ], "description": "Extracorp shockwv tx hi enrg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0100T", "type": "HCPCS" } ], "description": "Prosth Retina Receive&Gen", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0098T", "type": "HCPCS" } ], "description": "Rev Artific Disc Addl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0095T", "type": "HCPCS" } ], "description": "Rmvl artific disc addl crvcl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0076T", "type": "HCPCS" } ], "description": "S&I Stent/Chest Vert Art", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0075T", "type": "HCPCS" } ], "description": "Perq Stent/Chest Vert Art", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9785", "type": "HCPCS" } ], "description": "Endo outlet restrict w/tube", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9784", "type": "HCPCS" } ], "description": "Endo sleeve gastro w/tube", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1435", "type": "HCPCS" } ], "description": "Injection estrone per 1 MG", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1675", "type": "HCPCS" } ], "description": "Histrelin acetate", "standard_charges": [ { "billing_class": "facility", "maximum": 2.63, "minimum": 2.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J1730", "type": "HCPCS" } ], "description": "Diazoxide injection", "standard_charges": [ { "billing_class": "facility", "maximum": 266.47, "minimum": 266.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 266.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 266.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0810T", "type": "HCPCS" } ], "description": "Subrta njx rx agt w/vtrc", "standard_charges": [ { "billing_class": "facility", "maximum": 4011.54, "minimum": 3714.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4011.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0806T", "type": "HCPCS" } ], "description": "Tcat s&ivc prstc vl impl opn", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0805T", "type": "HCPCS" } ], "description": "Tcat s&ivc prstc vl impl prq", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0803T", "type": "HCPCS" } ], "description": "Tcat rmv&rpl2chmb ldls pm rv", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0802T", "type": "HCPCS" } ], "description": "Tcat rmv&rpl2chmb ldls pm ra", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0801T", "type": "HCPCS" } ], "description": "Tcat rmv&rpl 2chmbr ldls pm", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0800T", "type": "HCPCS" } ], "description": "Tcat rmvl 2chmbr ldls pm rv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0799T", "type": "HCPCS" } ], "description": "Tcat rmvl 2chmbr ldls pm ra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0798T", "type": "HCPCS" } ], "description": "Tcat rmv 2chmbr ldls pm cmpl", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0797T", "type": "HCPCS" } ], "description": "Tcat ins 2chmbr ldls pm rv", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0796T", "type": "HCPCS" } ], "description": "Tcat ins 2chmbr ldls pm ra", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0795T", "type": "HCPCS" } ], "description": "Tcat ins 2chmbr ldls pm cmpl", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0793T", "type": "HCPCS" } ], "description": "Prq tcat thrm ablt nrv p-art", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9792", "type": "HCPCS" } ], "description": "Blind/nonblind trans atrial", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9202.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9202.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9789", "type": "HCPCS" } ], "description": "Instill pharm renal pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1180.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1180.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7558", "type": "HCPCS" } ], "description": "Cor angio/vent w/drug admin", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7557", "type": "HCPCS" } ], "description": "Cor angio/vent w/ffr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7556", "type": "HCPCS" } ], "description": "Bronch lavage w/ebus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67516", "type": "HCPCS" } ], "description": "Sprchoroidal spc njx rx agt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64598", "type": "HCPCS" } ], "description": "Revj/rmvl nea pn w/int nstim", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64596", "type": "HCPCS" } ], "description": "Ins/rplcmt prq eltrd ra pn 1", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61892", "type": "HCPCS" } ], "description": "Rmv sk-mnt crnl nstm pg/rcvr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61891", "type": "HCPCS" } ], "description": "Rev/rplcmt sk-mnt crnl nstm", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61889", "type": "HCPCS" } ], "description": "Ins sk-mnt crnl nstm pg/rcvr", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58580", "type": "HCPCS" } ], "description": "Transcrv abltj utrn fibrd rf", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52284", "type": "HCPCS" } ], "description": "Cysto rx balo cath urtl strx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33288", "type": "HCPCS" } ], "description": "Rmv&rplcmt phrnc nrv stim ld", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33287", "type": "HCPCS" } ], "description": "Rmv&rplcmt phrnc nrv stim pg", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33281", "type": "HCPCS" } ], "description": "Reposg phrnc nrv stim trnsvn", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33280", "type": "HCPCS" } ], "description": "Rmvl phrnc nrv stim pg only", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33279", "type": "HCPCS" } ], "description": "Rmvl phrnc nrv stim transvns", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33278", "type": "HCPCS" } ], "description": "Rmvl phrnc nrv stim sys", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33276", "type": "HCPCS" } ], "description": "Insj phrnc nrv stim sys", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 42470.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42470.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31243", "type": "HCPCS" } ], "description": "Nsl/sinus ndsc cryoabltj pnn", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31242", "type": "HCPCS" } ], "description": "Nsl/sinus ndsc rf abltj pnn", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27278", "type": "HCPCS" } ], "description": "Arthrd si jt prq wo tfxj dev", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22838", "type": "HCPCS" } ], "description": "Rev rplc/rmv thrc vrt tethrg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22837", "type": "HCPCS" } ], "description": "Ant thrc vrt body tethrg 8+", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22836", "type": "HCPCS" } ], "description": "Ant thrc vrt body tethrg <7", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0863T", "type": "HCPCS" } ], "description": "Rlcj pg wcs lv trnsmtr only", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0862T", "type": "HCPCS" } ], "description": "Rlcj pg wcs lv battery only", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0861T", "type": "HCPCS" } ], "description": "Rmvl pg wcs lv both compnt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0825T", "type": "HCPCS" } ], "description": "Tcat rmv&rpl1chmb ldls pm ra", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0824T", "type": "HCPCS" } ], "description": "Tcat rmv 1chmbr ldls pm ra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0823T", "type": "HCPCS" } ], "description": "Tcat ins 1chmbr ldls pm ra", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0819T", "type": "HCPCS" } ], "description": "Revj/rmvl ins ptn subf", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0818T", "type": "HCPCS" } ], "description": "Revj/rmvl ins ptn subq", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0817T", "type": "HCPCS" } ], "description": "Opn insj/rplcmt ins ptn subf", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18706.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18706.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0816T", "type": "HCPCS" } ], "description": "Opn insj/rplcmt ins ptn subq", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18706.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18706.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0814T", "type": "HCPCS" } ], "description": "Prq njx biod osteo matrl fem", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0813T", "type": "HCPCS" } ], "description": "Egd vol adjmt bariatric balo", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0790T", "type": "HCPCS" } ], "description": "Revj rplcmt/rmvl vrt tethrg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0787T", "type": "HCPCS" } ], "description": "Revj/rmvl nea sac w/nstim", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0786T", "type": "HCPCS" } ], "description": "Insj/rplcmt prq ra sac nstim", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0785T", "type": "HCPCS" } ], "description": "Revj/rmvl nea spi w/nstim", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0784T", "type": "HCPCS" } ], "description": "Ins/rplmt eltrd ra spi nstim", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9797", "type": "HCPCS" } ], "description": "Vasc emb/occ w/prs cath", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9796", "type": "HCPCS" } ], "description": "Rpr intst excl anrect fist", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9901", "type": "HCPCS" } ], "description": "Endo defect closure GI tract", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0896T", "type": "HCPCS" } ], "description": "Connj lvr algrft prfu dev ea", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0895T", "type": "HCPCS" } ], "description": "Connj lvr algrft prfu dev 1", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0894T", "type": "HCPCS" } ], "description": "Cannulation liver allograft", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0888T", "type": "HCPCS" } ], "description": "Histotripsy mal renal tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 16516.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16516.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0886T", "type": "HCPCS" } ], "description": "Sgmdsc flx 1st tndsc dilat", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0885T", "type": "HCPCS" } ], "description": "Colsc flx 1st tndsc dilat", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0884T", "type": "HCPCS" } ], "description": "Esphgsc flx 1st tndsc dilat", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0874T", "type": "HCPCS" } ], "description": "Rmvl pertl ascites pmp sys", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0873T", "type": "HCPCS" } ], "description": "Revj subq prtl asct pmp sys", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0872T", "type": "HCPCS" } ], "description": "Rplcmt ndwllg bldr&prtl cath", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0871T", "type": "HCPCS" } ], "description": "Rplcmt subq prtl ascites pmp", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0870T", "type": "HCPCS" } ], "description": "Imp subq prtl ascts pmp sys", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0869T", "type": "HCPCS" } ], "description": "Njx b1 sub mtrl hw fixj aug", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0867T", "type": "HCPCS" } ], "description": "Tpla b9 prst8 hyprplsa>=50ml", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0565", "type": "HCPCS" } ], "description": "Rem/ins glu snsr 365 dif sit", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0564", "type": "HCPCS" } ], "description": "365 d implant glucose sensor", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8003", "type": "HCPCS" } ], "description": "Imp extar knee shck absrb", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8002", "type": "HCPCS" } ], "description": "Prep skin cell susp, automtd", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6842.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6842.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7565", "type": "HCPCS" } ], "description": "Rpr aa hrn < 3 rdc w/ rmvl", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7564", "type": "HCPCS" } ], "description": "Vein mech throm w/intrvas us", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7563", "type": "HCPCS" } ], "description": "Trluml ballo angiop all art", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7562", "type": "HCPCS" } ], "description": "R&l hrt angio w/ffr & 3d map", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66683", "type": "HCPCS" } ], "description": "Implantation iris prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 15871.89, "minimum": 9206.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15871.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61715", "type": "HCPCS" } ], "description": "Mrgfus strtctc ablt trgt icr", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60660", "type": "HCPCS" } ], "description": "Abltj 1/+thyr ndul 1lobe prq", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55882", "type": "HCPCS" } ], "description": "Ablt trurl prst8 tis trnsdcr", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 12721.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12721.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55881", "type": "HCPCS" } ], "description": "Ablt trurl prst8 tis thrm us", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53866", "type": "HCPCS" } ], "description": "Cathj rmvl dev ischmc rmdlg", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53865", "type": "HCPCS" } ], "description": "Cysto insj dev ischmc rmdlg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51721", "type": "HCPCS" } ], "description": "Ins trurl ablt trnsdc thr us", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49190", "type": "HCPCS" } ], "description": "Opn exc/dstr ntra-abd >30 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49189", "type": "HCPCS" } ], "description": "Opn exc/dst ntra-abd 20.1-30", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49188", "type": "HCPCS" } ], "description": "Opn exc/dst ntra-abd 10.1-20", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49187", "type": "HCPCS" } ], "description": "Opn exc/dstr ntra-abd 5.1-10", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49186", "type": "HCPCS" } ], "description": "Opn exc/dstr ntra-abd 5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38228", "type": "HCPCS" } ], "description": "Car-t admn autologous", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38227", "type": "HCPCS" } ], "description": "Car-t receipt&prepj admn", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38226", "type": "HCPCS" } ], "description": "Car-t prep t lymphcyt f/trns", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38225", "type": "HCPCS" } ], "description": "Car-t hrv bld-drv t lymphcyt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25448", "type": "HCPCS" } ], "description": "Arthrp ntrcrpl/crp/mtcrp ssp", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15017", "type": "HCPCS" } ], "description": "App skn cll ssp f/n/g/hf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15015", "type": "HCPCS" } ], "description": "App skn cl ssp agrft t/a/l 1", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15013", "type": "HCPCS" } ], "description": "Prepj skn cll ssp agrft 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 6842.88, "minimum": 3714.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6842.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15011", "type": "HCPCS" } ], "description": "Hrv skn cll ssp agrft 1st 25", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0943T", "type": "HCPCS" } ], "description": "Cysto flx rmvl urtl scaffold", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0942T", "type": "HCPCS" } ], "description": "Cysto flx rmv&rplc urtl scaf", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0941T", "type": "HCPCS" } ], "description": "Cysto flx ins&xpns urtl scaf", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0935T", "type": "HCPCS" } ], "description": "Cysto w/rnl pel symp dnrvtj", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0933T", "type": "HCPCS" } ], "description": "Tcat impl wrls l atr prs snr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3125.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3125.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0925T", "type": "HCPCS" } ], "description": "Rlcj skin pocket ccm-d pg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0924T", "type": "HCPCS" } ], "description": "Rpos prv ccm-d trnsvns eltrd", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0923T", "type": "HCPCS" } ], "description": "Rmvl&rplcmt perm ccm-d pg", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0922T", "type": "HCPCS" } ], "description": "Rmvl perm ccm-d sys dual ld", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0921T", "type": "HCPCS" } ], "description": "Rmvl perm ccm-d sys 1 dfb ld", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0920T", "type": "HCPCS" } ], "description": "Rmvl perm ccm-d sys 1 pac ld", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0919T", "type": "HCPCS" } ], "description": "Rmvl perm ccm-d sys pg only", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0918T", "type": "HCPCS" } ], "description": "Insj perm ccm-d sys dual ld", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0917T", "type": "HCPCS" } ], "description": "Insj perm ccm-d sys 1 lead", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0916T", "type": "HCPCS" } ], "description": "Insj perm ccm-d sys pg only", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0915T", "type": "HCPCS" } ], "description": "Insj perm ccm-d sys pg&eltrd", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 30265.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30265.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0910T", "type": "HCPCS" } ], "description": "Rmvl int nstim sys vagus nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0909T", "type": "HCPCS" } ], "description": "Rplcmt int nstim sys vgs nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0908T", "type": "HCPCS" } ], "description": "Opn imp int nstm sys vgs nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11004", "type": "HCPCS" } ], "description": "Debride genitalia & perineum", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11005", "type": "HCPCS" } ], "description": "Debride abdom wall", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11006", "type": "HCPCS" } ], "description": "Debride genit/per/abdom wall", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11008", "type": "HCPCS" } ], "description": "Remove mesh from abd wall", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11010", "type": "HCPCS" } ], "description": "Debride skin at fx site", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2002", "type": "HCPCS" } ], "description": "Inj, lidocaine in d5w, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.03, "minimum": 0.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 0.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2003", "type": "HCPCS" } ], "description": "Inj, lidocaine hcl, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 0.16, "minimum": 0.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2180", "type": "HCPCS" } ], "description": "Meperidine/promethazine inj", "standard_charges": [ { "billing_class": "facility", "maximum": 20.16, "minimum": 20.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11011", "type": "HCPCS" } ], "description": "Debride skin musc at fx site", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11012", "type": "HCPCS" } ], "description": "Deb skin bone at fx site", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11042", "type": "HCPCS" } ], "description": "Deb subq tissue 20 sq cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11043", "type": "HCPCS" } ], "description": "Deb musc/fascia 20 sq cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11044", "type": "HCPCS" } ], "description": "Deb bone 20 sq cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11055", "type": "HCPCS" } ], "description": "Trim skin lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11056", "type": "HCPCS" } ], "description": "Trim skin lesions 2 to 4", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11057", "type": "HCPCS" } ], "description": "Trim skin lesions over 4", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11102", "type": "HCPCS" } ], "description": "Tangntl bx skin single les", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11104", "type": "HCPCS" } ], "description": "Punch bx skin single lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11106", "type": "HCPCS" } ], "description": "Incal bx skn single les", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11200", "type": "HCPCS" } ], "description": "Removal of skin tags 2.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11305", "type": "HCPCS" } ], "description": "Shave skin lesion 0.5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11306", "type": "HCPCS" } ], "description": "Shave skin lesion 0.6-1.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11307", "type": "HCPCS" } ], "description": "Shave skin lesion 1.1-2.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11308", "type": "HCPCS" } ], "description": "Shave skin lesion >2.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11310", "type": "HCPCS" } ], "description": "Shave skin lesion 0.5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11311", "type": "HCPCS" } ], "description": "Shave skin lesion 0.6-1.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11312", "type": "HCPCS" } ], "description": "Shave skin lesion 1.1-2.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11313", "type": "HCPCS" } ], "description": "Shave skin lesion >2.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11400", "type": "HCPCS" } ], "description": "Exc tr-ext b9+marg 0.5 cm<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11401", "type": "HCPCS" } ], "description": "Exc tr-ext b9+marg 0.6-1 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11402", "type": "HCPCS" } ], "description": "Exc tr-ext b9+marg 1.1-2 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11403", "type": "HCPCS" } ], "description": "Exc tr-ext b9+marg 2.1-3cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11404", "type": "HCPCS" } ], "description": "Exc tr-ext b9+marg 3.1-4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11406", "type": "HCPCS" } ], "description": "Exc tr-ext b9+marg >4.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11420", "type": "HCPCS" } ], "description": "Exc h-f-nk-sp b9+marg 0.5/<", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11421", "type": "HCPCS" } ], "description": "Exc h-f-nk-sp b9+marg 0.6-1", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11422", "type": "HCPCS" } ], "description": "Exc h-f-nk-sp b9+marg 1.1-2", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11423", "type": "HCPCS" } ], "description": "Exc h-f-nk-sp b9+marg 2.1-3", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11424", "type": "HCPCS" } ], "description": "Exc h-f-nk-sp b9+marg 3.1-4", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11426", "type": "HCPCS" } ], "description": "Exc h-f-nk-sp b9+marg >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11440", "type": "HCPCS" } ], "description": "Exc face-mm b9+marg 0.5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11441", "type": "HCPCS" } ], "description": "Exc face-mm b9+marg 0.6-1 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11442", "type": "HCPCS" } ], "description": "Exc face-mm b9+marg 1.1-2 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11443", "type": "HCPCS" } ], "description": "Exc face-mm b9+marg 2.1-3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11444", "type": "HCPCS" } ], "description": "Exc face-mm b9+marg 3.1-4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11446", "type": "HCPCS" } ], "description": "Exc face-mm b9+marg >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11450", "type": "HCPCS" } ], "description": "Removal sweat gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11451", "type": "HCPCS" } ], "description": "Removal sweat gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11462", "type": "HCPCS" } ], "description": "Removal sweat gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11463", "type": "HCPCS" } ], "description": "Removal sweat gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11470", "type": "HCPCS" } ], "description": "Removal sweat gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11471", "type": "HCPCS" } ], "description": "Removal sweat gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11600", "type": "HCPCS" } ], "description": "Exc tr-ext mal+marg 0.5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11601", "type": "HCPCS" } ], "description": "Exc tr-ext mal+marg 0.6-1 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11602", "type": "HCPCS" } ], "description": "Exc tr-ext mal+marg 1.1-2 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11603", "type": "HCPCS" } ], "description": "Exc tr-ext mal+marg 2.1-3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11604", "type": "HCPCS" } ], "description": "Exc tr-ext mal+marg 3.1-4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11606", "type": "HCPCS" } ], "description": "Exc tr-ext mal+marg >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11620", "type": "HCPCS" } ], "description": "Exc h-f-nk-sp mal+marg 0.5/<", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11621", "type": "HCPCS" } ], "description": "Exc s/n/h/f/g mal+mrg 0.6-1", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11622", "type": "HCPCS" } ], "description": "Exc s/n/h/f/g mal+mrg 1.1-2", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11623", "type": "HCPCS" } ], "description": "Exc s/n/h/f/g mal+mrg 2.1-3", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11624", "type": "HCPCS" } ], "description": "Exc s/n/h/f/g mal+mrg 3.1-4", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11626", "type": "HCPCS" } ], "description": "Exc s/n/h/f/g mal+mrg >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11640", "type": "HCPCS" } ], "description": "Exc f/e/e/n/l mal+mrg 0.5cm<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11641", "type": "HCPCS" } ], "description": "Exc f/e/e/n/l mal+mrg 0.6-1", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11642", "type": "HCPCS" } ], "description": "Exc f/e/e/n/l mal+mrg 1.1-2", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11643", "type": "HCPCS" } ], "description": "Exc f/e/e/n/l mal+mrg 2.1-3", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11644", "type": "HCPCS" } ], "description": "Exc f/e/e/n/l mal+mrg 3.1-4", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11646", "type": "HCPCS" } ], "description": "Exc f/e/e/n/l mal+mrg >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11719", "type": "HCPCS" } ], "description": "Trim nail(s) any number", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11720", "type": "HCPCS" } ], "description": "Debride nail 1-5", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11721", "type": "HCPCS" } ], "description": "Debride nail 6 or more", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11730", "type": "HCPCS" } ], "description": "Removal of nail plate", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11740", "type": "HCPCS" } ], "description": "Drain blood from under nail", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11750", "type": "HCPCS" } ], "description": "Removal of nail bed", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11755", "type": "HCPCS" } ], "description": "Biopsy nail unit", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11760", "type": "HCPCS" } ], "description": "Repair of nail bed", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11762", "type": "HCPCS" } ], "description": "Reconstruction of nail bed", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11765", "type": "HCPCS" } ], "description": "Excision of nail fold toe", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11770", "type": "HCPCS" } ], "description": "Remove pilonidal cyst simple", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11771", "type": "HCPCS" } ], "description": "Remove pilonidal cyst exten", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11772", "type": "HCPCS" } ], "description": "Remove pilonidal cyst compl", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11900", "type": "HCPCS" } ], "description": "Inject skin lesions <=w 7", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11901", "type": "HCPCS" } ], "description": "Inject skin lesions >7", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11920", "type": "HCPCS" } ], "description": "Correct skin color 6.0 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11921", "type": "HCPCS" } ], "description": "Correct skn color 6.1-20.0cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11950", "type": "HCPCS" } ], "description": "Tx contour defects 1 cc/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11951", "type": "HCPCS" } ], "description": "Tx contour defects 1.1-5.0cc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11952", "type": "HCPCS" } ], "description": "Tx contour defects 5.1-10cc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11954", "type": "HCPCS" } ], "description": "Tx contour defects >10.0 cc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11960", "type": "HCPCS" } ], "description": "Insert tissue expander(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11970", "type": "HCPCS" } ], "description": "Replace tissue expander", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11971", "type": "HCPCS" } ], "description": "Remove tissue expander(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11976", "type": "HCPCS" } ], "description": "Remove contraceptive capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11980", "type": "HCPCS" } ], "description": "Implant hormone pellet(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11981", "type": "HCPCS" } ], "description": "Insert drug implant device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11982", "type": "HCPCS" } ], "description": "Remove drug implant device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "11983", "type": "HCPCS" } ], "description": "Remove/insert drug implant", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12001", "type": "HCPCS" } ], "description": "Rpr s/n/ax/gen/trnk 2.5cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12002", "type": "HCPCS" } ], "description": "Rpr s/n/ax/gen/trnk2.6-7.5cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12004", "type": "HCPCS" } ], "description": "Rpr s/n/ax/gen/trk7.6-12.5cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12005", "type": "HCPCS" } ], "description": "Rpr s/n/a/gen/trk12.6-20.0cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12006", "type": "HCPCS" } ], "description": "Rpr s/n/a/gen/trk20.1-30.0cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12007", "type": "HCPCS" } ], "description": "Rpr s/n/ax/gen/trnk >30.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12011", "type": "HCPCS" } ], "description": "Rpr f/e/e/n/l/m 2.5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12013", "type": "HCPCS" } ], "description": "Rpr f/e/e/n/l/m 2.6-5.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12014", "type": "HCPCS" } ], "description": "Rpr f/e/e/n/l/m 5.1-7.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12015", "type": "HCPCS" } ], "description": "Rpr f/e/e/n/l/m 7.6-12.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12016", "type": "HCPCS" } ], "description": "Rpr fe/e/en/l/m 12.6-20.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12017", "type": "HCPCS" } ], "description": "Rpr fe/e/en/l/m 20.1-30.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12018", "type": "HCPCS" } ], "description": "Rpr f/e/e/n/l/m >30.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12020", "type": "HCPCS" } ], "description": "Closure of split wound", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12021", "type": "HCPCS" } ], "description": "Closure of split wound", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12031", "type": "HCPCS" } ], "description": "Intmd rpr s/a/t/ext 2.5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12032", "type": "HCPCS" } ], "description": "Intmd rpr s/a/t/ext 2.6-7.5", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12034", "type": "HCPCS" } ], "description": "Intmd rpr s/tr/ext 7.6-12.5", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12035", "type": "HCPCS" } ], "description": "Intmd rpr s/a/t/ext 12.6-20", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12036", "type": "HCPCS" } ], "description": "Intmd rpr s/a/t/ext 20.1-30", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12037", "type": "HCPCS" } ], "description": "Intmd rpr s/tr/ext >30.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12041", "type": "HCPCS" } ], "description": "Intmd rpr n-hf/genit 2.5cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12042", "type": "HCPCS" } ], "description": "Intmd rpr n-hf/genit2.6-7.5", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12044", "type": "HCPCS" } ], "description": "Intmd rpr n-hf/genit7.6-12.5", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12045", "type": "HCPCS" } ], "description": "Intmd rpr n-hf/genit12.6-20", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12046", "type": "HCPCS" } ], "description": "Intmd rpr n-hf/genit20.1-30", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12047", "type": "HCPCS" } ], "description": "Intmd rpr n-hf/genit >30.0cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12051", "type": "HCPCS" } ], "description": "Intmd rpr face/mm 2.5 cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12052", "type": "HCPCS" } ], "description": "Intmd rpr face/mm 2.6-5.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12053", "type": "HCPCS" } ], "description": "Intmd rpr face/mm 5.1-7.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12054", "type": "HCPCS" } ], "description": "Intmd rpr face/mm 7.6-12.5cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12055", "type": "HCPCS" } ], "description": "Intmd rpr face/mm 12.6-20 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12056", "type": "HCPCS" } ], "description": "Intmd rpr face/mm 20.1-30.0", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "12057", "type": "HCPCS" } ], "description": "Intmd rpr face/mm >30.0 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13100", "type": "HCPCS" } ], "description": "Cmplx rpr trunk 1.1-2.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13101", "type": "HCPCS" } ], "description": "Cmplx rpr trunk 2.6-7.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13120", "type": "HCPCS" } ], "description": "Cmplx rpr s/a/l 1.1-2.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13121", "type": "HCPCS" } ], "description": "Cmplx rpr s/a/l 2.6-7.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13131", "type": "HCPCS" } ], "description": "Cmplx rpr f/c/c/m/n/ax/g/h/f", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13132", "type": "HCPCS" } ], "description": "Cmplx rpr f/c/c/m/n/ax/g/h/f", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13151", "type": "HCPCS" } ], "description": "Cmplx rpr e/n/e/l 1.1-2.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13152", "type": "HCPCS" } ], "description": "Cmplx rpr e/n/e/l 2.6-7.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "13160", "type": "HCPCS" } ], "description": "Late closure of wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14000", "type": "HCPCS" } ], "description": "Tis trnfr trunk 10 sq cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14001", "type": "HCPCS" } ], "description": "Tis trnfr trunk 10.1-30sqcm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14020", "type": "HCPCS" } ], "description": "Tis trnfr s/a/l 10 sq cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14021", "type": "HCPCS" } ], "description": "Tis trnfr s/a/l 10.1-30 sqcm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14040", "type": "HCPCS" } ], "description": "Tis trnfr f/c/c/m/n/a/g/h/f", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14041", "type": "HCPCS" } ], "description": "Tis trnfr f/c/c/m/n/a/g/h/f", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14060", "type": "HCPCS" } ], "description": "Tis trnfr e/n/e/l 10 sq cm/<", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14061", "type": "HCPCS" } ], "description": "Tis trnfr e/n/e/l10.1-30sqcm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14301", "type": "HCPCS" } ], "description": "Tis trnfr any 30.1-60 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "14350", "type": "HCPCS" } ], "description": "Filleted finger/toe flap", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15002", "type": "HCPCS" } ], "description": "Wound prep trk/arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15004", "type": "HCPCS" } ], "description": "Wound prep f/n/hf/g", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15040", "type": "HCPCS" } ], "description": "Harvest cultured skin graft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15050", "type": "HCPCS" } ], "description": "Skin pinch graft", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15100", "type": "HCPCS" } ], "description": "Skin splt grft trnk/arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15110", "type": "HCPCS" } ], "description": "Epidrm autogrft trnk/arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15115", "type": "HCPCS" } ], "description": "Epidrm a-grft face/nck/hf/g", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15120", "type": "HCPCS" } ], "description": "Skn splt a-grft fac/nck/hf/g", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15130", "type": "HCPCS" } ], "description": "Derm autograft trnk/arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15135", "type": "HCPCS" } ], "description": "Derm autograft face/nck/hf/g", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15150", "type": "HCPCS" } ], "description": "Cult skin grft t/arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15155", "type": "HCPCS" } ], "description": "Cult skin graft f/n/hf/g", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15200", "type": "HCPCS" } ], "description": "Skin full graft trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15220", "type": "HCPCS" } ], "description": "Skin full graft sclp/arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15240", "type": "HCPCS" } ], "description": "Skin full grft face/genit/hf", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15260", "type": "HCPCS" } ], "description": "Skin full graft een & lips", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15271", "type": "HCPCS" } ], "description": "Skin sub graft trnk/arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15273", "type": "HCPCS" } ], "description": "Skin sub grft t/arm/lg child", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15275", "type": "HCPCS" } ], "description": "Skin sub graft face/nk/hf/g", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15277", "type": "HCPCS" } ], "description": "Skn sub grft f/n/hf/g child", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15570", "type": "HCPCS" } ], "description": "Skin pedicle flap trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15572", "type": "HCPCS" } ], "description": "Skin pedicle flap arms/legs", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15574", "type": "HCPCS" } ], "description": "Pedcle fh/ch/ch/m/n/ax/g/h/f", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15576", "type": "HCPCS" } ], "description": "Pedicle e/n/e/l/ntroral", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15600", "type": "HCPCS" } ], "description": "Delay flap trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15610", "type": "HCPCS" } ], "description": "Delay flap arms/legs", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15620", "type": "HCPCS" } ], "description": "Delay flap f/c/c/n/ax/g/h/f", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15630", "type": "HCPCS" } ], "description": "Delay flap eye/nos/ear/lip", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15650", "type": "HCPCS" } ], "description": "Transfer skin pedicle flap", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15730", "type": "HCPCS" } ], "description": "Mdfc flap w/prsrv vasc pedcl", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15731", "type": "HCPCS" } ], "description": "Forehead Flap w/Vasc Pedicle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15733", "type": "HCPCS" } ], "description": "Musc myoq/fscq flp h&n pedcl", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15734", "type": "HCPCS" } ], "description": "Muscle-skin graft trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15736", "type": "HCPCS" } ], "description": "Muscle-skin graft arm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15738", "type": "HCPCS" } ], "description": "Muscle-skin graft leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15740", "type": "HCPCS" } ], "description": "Island pedicle flap graft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15750", "type": "HCPCS" } ], "description": "Neurovascular pedicle flap", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15756", "type": "HCPCS" } ], "description": "Free myo/skin flap microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15757", "type": "HCPCS" } ], "description": "Free skin flap microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15758", "type": "HCPCS" } ], "description": "Free fascial flap microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15760", "type": "HCPCS" } ], "description": "Composite skin graft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15769", "type": "HCPCS" } ], "description": "Grfg autol soft tiss dir exc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15770", "type": "HCPCS" } ], "description": "Derma-fat-fascia graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15771", "type": "HCPCS" } ], "description": "Grfg autol fat lipo 50 cc/<", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15773", "type": "HCPCS" } ], "description": "Grfg autol fat lipo 25 cc/<", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15775", "type": "HCPCS" } ], "description": "Hair trnspl 1-15 punch grfts", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15776", "type": "HCPCS" } ], "description": "Hair trnspl >15 punch grafts", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15778", "type": "HCPCS" } ], "description": "Impl absrb msh/prsth dly cls", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15780", "type": "HCPCS" } ], "description": "Dermabrasion total face", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15781", "type": "HCPCS" } ], "description": "Dermabrasion segmental face", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15782", "type": "HCPCS" } ], "description": "Dermabrasion other than face", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15783", "type": "HCPCS" } ], "description": "Dermabrasion suprfl any site", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15786", "type": "HCPCS" } ], "description": "Abrasion lesion single", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15788", "type": "HCPCS" } ], "description": "Chemical peel face epiderm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15789", "type": "HCPCS" } ], "description": "Chemical peel face dermal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15792", "type": "HCPCS" } ], "description": "Chemical peel nonfacial", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15793", "type": "HCPCS" } ], "description": "Chemical peel nonfacial", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15819", "type": "HCPCS" } ], "description": "Plastic surgery neck", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15820", "type": "HCPCS" } ], "description": "Revision of lower eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15821", "type": "HCPCS" } ], "description": "Revision of lower eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15822", "type": "HCPCS" } ], "description": "Revision of upper eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15823", "type": "HCPCS" } ], "description": "Revision of upper eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15824", "type": "HCPCS" } ], "description": "Removal of forehead wrinkles", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15825", "type": "HCPCS" } ], "description": "Removal of neck wrinkles", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15826", "type": "HCPCS" } ], "description": "Removal of brow wrinkles", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15828", "type": "HCPCS" } ], "description": "Removal of face wrinkles", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15829", "type": "HCPCS" } ], "description": "Removal of skin wrinkles", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15830", "type": "HCPCS" } ], "description": "Exc Skin Abd", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15832", "type": "HCPCS" } ], "description": "Excise excessive skin thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15833", "type": "HCPCS" } ], "description": "Excise excessive skin leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15834", "type": "HCPCS" } ], "description": "Excise excessive skin hip", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15835", "type": "HCPCS" } ], "description": "Excise excessive skin buttck", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15836", "type": "HCPCS" } ], "description": "Excise excessive skin arm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15837", "type": "HCPCS" } ], "description": "Excise excess skin arm/hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15838", "type": "HCPCS" } ], "description": "Excise excess skin fat pad", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15839", "type": "HCPCS" } ], "description": "Excise excess skin & tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15840", "type": "HCPCS" } ], "description": "Nerve palsy fascial graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15841", "type": "HCPCS" } ], "description": "Nerve palsy muscle graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15842", "type": "HCPCS" } ], "description": "Nerve palsy microsurg graft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15845", "type": "HCPCS" } ], "description": "Skin and muscle repair face", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15850", "type": "HCPCS" } ], "description": "Remove sutures same surgeon", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15851", "type": "HCPCS" } ], "description": "Remove sutures diff surgeon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15852", "type": "HCPCS" } ], "description": "Dressing change not for burn", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15860", "type": "HCPCS" } ], "description": "Test for blood flow in graft", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15876", "type": "HCPCS" } ], "description": "Suction lipectomy head&neck", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15877", "type": "HCPCS" } ], "description": "Suction lipectomy trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15878", "type": "HCPCS" } ], "description": "Suction lipectomy upr extrem", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15879", "type": "HCPCS" } ], "description": "Suction lipectomy lwr extrem", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15920", "type": "HCPCS" } ], "description": "Removal of tail bone ulcer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15922", "type": "HCPCS" } ], "description": "Removal of tail bone ulcer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15931", "type": "HCPCS" } ], "description": "Remove sacrum pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15933", "type": "HCPCS" } ], "description": "Remove sacrum pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15934", "type": "HCPCS" } ], "description": "Remove sacrum pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15935", "type": "HCPCS" } ], "description": "Remove sacrum pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15936", "type": "HCPCS" } ], "description": "Remove sacrum pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15937", "type": "HCPCS" } ], "description": "Remove sacrum pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15940", "type": "HCPCS" } ], "description": "Remove hip pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15941", "type": "HCPCS" } ], "description": "Remove hip pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15944", "type": "HCPCS" } ], "description": "Remove hip pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15945", "type": "HCPCS" } ], "description": "Remove hip pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15946", "type": "HCPCS" } ], "description": "Remove hip pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15950", "type": "HCPCS" } ], "description": "Remove thigh pressure 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"setting": "outpatient" } ] }, { "code_information": [ { "code": "15952", "type": "HCPCS" } ], "description": "Remove thigh pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "15953", "type": "HCPCS" } ], "description": "Remove thigh pressure sore", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { 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"Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "16035", "type": "HCPCS" } ], "description": "Incision of burn scab initi", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "16036", "type": "HCPCS" } ], "description": "Escharotomy addl incision", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17000", "type": "HCPCS" } ], "description": "Destruct premalg lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17004", "type": "HCPCS" } ], "description": "Destroy premal lesions 15/>", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", 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"outpatient" } ] }, { "code_information": [ { "code": "17250", "type": "HCPCS" } ], "description": "Chemical cautery tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17260", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17261", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17262", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17263", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17264", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17266", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17270", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17271", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17272", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17273", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17274", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17276", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { 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lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17282", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": 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schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17286", "type": "HCPCS" } ], "description": "Destruction of skin lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17311", "type": "HCPCS" } ], "description": "Mohs 1 stage h/n/hf/g", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17313", "type": "HCPCS" } ], "description": "Mohs 1 stage t/a/l", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17340", "type": "HCPCS" } ], "description": "Cryotherapy of skin", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17360", "type": "HCPCS" } ], "description": "Skin peel therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17380", "type": "HCPCS" } ], "description": "Hair removal by electrolysis", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "17999", "type": "HCPCS" } ], "description": "Skin tissue procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19000", "type": "HCPCS" } ], "description": "Drainage of breast lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19020", "type": "HCPCS" } ], "description": "Incision of breast lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19081", "type": "HCPCS" } ], "description": "Bx breast 1st lesion strtctc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19083", "type": "HCPCS" } ], "description": "Bx breast 1st lesion us imag", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { 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image", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19101", "type": "HCPCS" } ], "description": "Biopsy of breast open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19105", "type": "HCPCS" } ], "description": "Cryosurg ablate fa each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19110", "type": "HCPCS" } ], "description": "Nipple exploration", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19112", "type": "HCPCS" } ], "description": "Excise breast duct fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19120", "type": "HCPCS" } ], "description": "Removal of breast lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19125", "type": "HCPCS" } ], "description": "Excision breast lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19281", "type": "HCPCS" } ], "description": "Perq device breast 1st imag", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19283", "type": "HCPCS" } ], "description": "Perq dev breast 1st strtctc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19285", "type": "HCPCS" } ], "description": "Perq dev breast 1st us imag", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19287", "type": "HCPCS" } ], "description": "Perq dev breast 1st mr guide", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19296", "type": "HCPCS" } ], "description": "Place po breast cath for rad", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7880.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7880.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19298", "type": "HCPCS" } ], "description": "Place breast rad tube/caths", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 13287.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13287.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19300", "type": "HCPCS" } ], "description": "Removal of Breast Tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19301", "type": "HCPCS" } ], "description": "Partial Mastectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19302", "type": "HCPCS" } ], "description": "P-Mastectomy w/LN Removal", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19303", "type": "HCPCS" } ], "description": "Mast simple complete", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19305", "type": "HCPCS" } ], "description": "Mast radical", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19306", "type": "HCPCS" } ], "description": "Mast rad urban type", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19307", "type": "HCPCS" } ], "description": "Mast mod rad", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19316", "type": "HCPCS" } ], "description": "Suspension of breast", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19318", "type": "HCPCS" } ], "description": "Reduction of large breast", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19325", "type": "HCPCS" } ], "description": "Enlarge breast with implant", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7880.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7880.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19328", "type": "HCPCS" } ], "description": "Removal of breast implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19330", "type": "HCPCS" } ], "description": "Removal of implant material", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "19340", "type": "HCPCS" } ], "description": "Immediate breast prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 7880.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7880.96 }, { 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"payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20206", "type": "HCPCS" } ], "description": "Needle biopsy muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20220", "type": "HCPCS" } ], "description": "Bone biopsy trocar/needle", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": 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31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20500", "type": "HCPCS" } ], "description": "Injection of sinus tract", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20520", "type": "HCPCS" } ], "description": "Removal of foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20525", "type": "HCPCS" } ], "description": "Removal of foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20526", "type": "HCPCS" } ], "description": "Ther injection carp tunnel", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20527", "type": "HCPCS" } ], "description": "Inj dupuytren cord w/enzyme", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20550", "type": "HCPCS" } ], "description": "Inj tendon sheath/ligament", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20551", "type": "HCPCS" } ], "description": "Inj tendon origin/insertion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20552", "type": "HCPCS" } ], "description": "Inj trigger point 1/2 muscl", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20553", "type": "HCPCS" } ], "description": "Inject trigger points 3/>", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20555", "type": "HCPCS" } ], "description": "Place ndl musc/tis for rt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20560", "type": "HCPCS" } ], "description": "Ndl insj w/o njx 1 or 2 musc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20561", "type": "HCPCS" } ], "description": "Ndl insj w/o njx 3+ musc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20600", "type": "HCPCS" } ], "description": "Drain/inj joint/bursa w/o us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20604", "type": "HCPCS" } ], "description": "Drain/inj joint/bursa w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20605", "type": "HCPCS" } ], "description": "Drain/inj joint/bursa w/o us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20606", "type": "HCPCS" } ], "description": "Drain/inj joint/bursa w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20610", "type": "HCPCS" } ], "description": "Drain/inj joint/bursa w/o us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20611", "type": "HCPCS" } ], "description": "Drain/inj joint/bursa w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20612", "type": "HCPCS" } ], "description": "Aspirate/inj ganglion cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20615", "type": "HCPCS" } ], "description": "Treatment of bone cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20650", "type": "HCPCS" } ], "description": "Insert and remove bone pin", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20660", "type": "HCPCS" } ], "description": "Apply rem fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20661", "type": "HCPCS" } ], "description": "Application of head brace", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20662", "type": "HCPCS" } ], "description": "Application of pelvis brace", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20663", "type": "HCPCS" } ], "description": "Application of thigh brace", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20664", "type": "HCPCS" } ], "description": "Application of halo", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20665", "type": "HCPCS" } ], "description": "Removal of fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20670", "type": "HCPCS" } ], "description": "Removal of support implant", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20680", "type": "HCPCS" } ], "description": "Removal of support implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20690", "type": "HCPCS" } ], "description": "Apply bone fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20692", "type": "HCPCS" } ], "description": "Apply bone fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J2995", "type": "HCPCS" } ], "description": "Inj streptokinase /250000 IU", "standard_charges": [ { "billing_class": "facility", "maximum": 192.84, "minimum": 192.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20693", "type": "HCPCS" } ], "description": "Adjust bone fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20694", "type": "HCPCS" } ], "description": "Remove bone fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20696", "type": "HCPCS" } ], "description": "Comp multiplane ext fixation", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 26163.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26163.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20697", "type": "HCPCS" } ], "description": "Comp ext fixate strut change", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20802", "type": "HCPCS" } ], "description": "Replantation arm complete", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20805", "type": "HCPCS" } ], "description": "Replant forearm complete", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20808", "type": "HCPCS" } ], "description": "Replantation hand complete", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20816", "type": "HCPCS" } ], "description": "Replantation digit complete", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20822", "type": "HCPCS" } ], "description": "Replantation digit complete", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20824", "type": "HCPCS" } ], "description": "Replantation thumb complete", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20827", "type": "HCPCS" } ], "description": "Replantation thumb complete", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20838", "type": "HCPCS" } ], "description": "Replantation foot complete", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20900", "type": "HCPCS" } ], "description": "Removal of bone for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20902", "type": "HCPCS" } ], "description": "Removal of bone for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20910", "type": "HCPCS" } ], "description": "Remove cartilage for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 712.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20912", "type": "HCPCS" } ], "description": "Remove cartilage for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20920", "type": "HCPCS" } ], "description": "Removal of fascia for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20922", "type": "HCPCS" } ], "description": "Removal of fascia for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20924", "type": "HCPCS" } ], "description": "Removal of tendon for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20950", "type": "HCPCS" } ], "description": "Fluid pressure muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20955", "type": "HCPCS" } ], "description": "Fibula bone graft microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20956", "type": "HCPCS" } ], "description": "Iliac bone graft microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20957", "type": "HCPCS" } ], "description": "Mt bone graft microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20962", "type": "HCPCS" } ], "description": "Other bone graft microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20969", "type": "HCPCS" } ], "description": "Bone/skin graft microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20970", "type": "HCPCS" } ], "description": "Bone/skin graft iliac crest", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20972", "type": "HCPCS" } ], "description": "Bone/skin graft metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20973", "type": "HCPCS" } ], "description": "Bone/skin graft great toe", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20974", "type": "HCPCS" } ], "description": "Electrical bone stimulation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 48.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20979", "type": "HCPCS" } ], "description": "Us bone stimulation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20982", "type": "HCPCS" } ], "description": "Ablate bone tumor(s) perq", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20983", "type": "HCPCS" } ], "description": "Ablate bone tumor(s) perq", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "20999", "type": "HCPCS" } ], "description": "Musculoskeletal surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21010", "type": "HCPCS" } ], "description": "Incision of jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21011", "type": "HCPCS" } ], "description": "Exc face les sc <2 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21012", "type": "HCPCS" } ], "description": "Exc face les sbq 2 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21013", "type": "HCPCS" } ], "description": "Exc face tum deep < 2 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21014", "type": "HCPCS" } ], "description": "Exc face tum deep 2 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21015", "type": "HCPCS" } ], "description": "Resect face/scalp tum < 2 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21016", "type": "HCPCS" } ], "description": "Resect face/scalp tum 2 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21025", "type": "HCPCS" } ], "description": "Excision of bone lower jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21026", "type": "HCPCS" } ], "description": "Excision of facial bone(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21029", "type": "HCPCS" } ], "description": "Contour of face bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21030", "type": "HCPCS" } ], "description": "Excise max/zygoma b9 tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21031", "type": "HCPCS" } ], "description": "Remove exostosis mandible", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21032", "type": "HCPCS" } ], "description": "Remove exostosis maxilla", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21034", "type": "HCPCS" } ], "description": "Excise max/zygoma mal tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21040", "type": "HCPCS" } ], "description": "Excise mandible lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21044", "type": "HCPCS" } ], "description": "Removal of jaw bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21045", "type": "HCPCS" } ], "description": "Extensive jaw surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21046", "type": "HCPCS" } ], "description": "Remove mandible cyst complex", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21047", "type": "HCPCS" } ], "description": "Excise lwr jaw cyst w/repair", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21048", "type": "HCPCS" } ], "description": "Remove maxilla cyst complex", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21049", "type": "HCPCS" } ], "description": "Excis uppr jaw cyst w/repair", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21050", "type": "HCPCS" } ], "description": "Removal of jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21060", "type": "HCPCS" } ], "description": "Remove jaw joint cartilage", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21070", "type": "HCPCS" } ], "description": "Remove coronoid process", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21073", "type": "HCPCS" } ], "description": "Mnpj of tmj w/anesth", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21076", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21077", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21079", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21080", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21081", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21082", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21083", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21084", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21085", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21086", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21087", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21088", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21089", "type": "HCPCS" } ], "description": "Prepare face/oral prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21100", "type": "HCPCS" } ], "description": "Maxillofacial fixation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21110", "type": "HCPCS" } ], "description": "Interdental fixation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21120", "type": "HCPCS" } ], "description": "Reconstruction of chin", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21121", "type": "HCPCS" } ], "description": "Reconstruction of chin", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21122", "type": "HCPCS" } ], "description": "Reconstruction of chin", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21123", "type": "HCPCS" } ], "description": "Reconstruction of chin", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21125", "type": "HCPCS" } ], "description": "Augmentation lower jaw bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21127", "type": "HCPCS" } ], "description": "Augmentation lower jaw bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21137", "type": "HCPCS" } ], "description": "Reduction of forehead", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21138", "type": "HCPCS" } ], "description": "Reduction of forehead", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21139", "type": "HCPCS" } ], "description": "Reduction of forehead", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21141", "type": "HCPCS" } ], "description": "Lefort i-1 piece w/o graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21142", "type": "HCPCS" } ], "description": "Lefort i-2 piece w/o graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21143", "type": "HCPCS" } ], "description": "Lefort i-3/> piece w/o graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21145", "type": "HCPCS" } ], "description": "Lefort i-1 piece w/ graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21146", "type": "HCPCS" } ], "description": "Lefort i-2 piece w/ graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21147", "type": "HCPCS" } ], "description": "Lefort i-3/> piece w/ graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21150", "type": "HCPCS" } ], "description": "Lefort ii anterior intrusion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21151", "type": "HCPCS" } ], "description": "Lefort ii w/bone grafts", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21154", "type": "HCPCS" } ], "description": "Lefort iii w/o lefort i", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21155", "type": "HCPCS" } ], "description": "Lefort iii w/ lefort i", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21159", "type": "HCPCS" } ], "description": "Lefort iii w/fhdw/o lefort i", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21160", "type": "HCPCS" } ], "description": "Lefort iii w/fhd w/ lefort i", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21172", "type": "HCPCS" } ], "description": "Reconstruct orbit/forehead", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21175", "type": "HCPCS" } ], "description": "Reconstruct orbit/forehead", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21179", "type": "HCPCS" } ], "description": "Reconstruct entire forehead", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21180", "type": "HCPCS" } ], "description": "Reconstruct entire forehead", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21181", "type": "HCPCS" } ], "description": "Contour cranial bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21182", "type": "HCPCS" } ], "description": "Reconstruct cranial bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21183", "type": "HCPCS" } ], "description": "Reconstruct cranial bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21184", "type": "HCPCS" } ], "description": "Reconstruct cranial bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21188", "type": "HCPCS" } ], "description": "Reconstruction of midface", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21193", "type": "HCPCS" } ], "description": "Reconst lwr jaw w/o graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21194", "type": "HCPCS" } ], "description": "Reconst lwr jaw w/graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21195", "type": "HCPCS" } ], "description": "Reconst lwr jaw w/o fixation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21196", "type": "HCPCS" } ], "description": "Reconst lwr jaw w/fixation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21198", "type": "HCPCS" } ], "description": "Reconstr lwr jaw segment", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21199", "type": "HCPCS" } ], "description": "Reconstr Lwr Jaw W/Advance", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21206", "type": "HCPCS" } ], "description": "Reconstruct upper jaw bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21208", "type": "HCPCS" } ], "description": "Augmentation of facial bones", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21209", "type": "HCPCS" } ], "description": "Reduction of facial bones", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21210", "type": "HCPCS" } ], "description": "Face bone graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21215", "type": "HCPCS" } ], "description": "Lower jaw bone graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21230", "type": "HCPCS" } ], "description": "Rib cartilage graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21235", "type": "HCPCS" } ], "description": "Ear cartilage graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21240", "type": "HCPCS" } ], "description": "Reconstruction of jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21242", "type": "HCPCS" } ], "description": "Reconstruction of jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21243", "type": "HCPCS" } ], "description": "Reconstruction of jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 26163.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26163.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21244", "type": "HCPCS" } ], "description": "Reconstruction of lower jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21245", "type": "HCPCS" } ], "description": "Reconstruction of jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21246", "type": "HCPCS" } ], "description": "Reconstruction of jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21247", "type": "HCPCS" } ], "description": "Reconstruct lower jaw bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21248", "type": "HCPCS" } ], "description": "Reconstruction of jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21249", "type": "HCPCS" } ], "description": "Reconstruction of jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21255", "type": "HCPCS" } ], "description": "Reconstruct lower jaw bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21256", "type": "HCPCS" } ], "description": "Reconstruction of orbit", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21260", "type": "HCPCS" } ], "description": "Revise eye sockets", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21261", "type": "HCPCS" } ], "description": "Revise eye sockets", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21263", "type": "HCPCS" } ], "description": "Revise eye sockets", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21267", "type": "HCPCS" } ], "description": "Revise eye sockets", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21268", "type": "HCPCS" } ], "description": "Revise eye sockets", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21270", "type": "HCPCS" } ], "description": "Augmentation cheek bone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21275", "type": "HCPCS" } ], "description": "Revision orbitofacial bones", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21280", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21282", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21295", "type": "HCPCS" } ], "description": "Revision of jaw muscle/bone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21296", "type": "HCPCS" } ], "description": "Revision of jaw muscle/bone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21299", "type": "HCPCS" } ], "description": "Cranio/maxillofacial surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21315", "type": "HCPCS" } ], "description": "Closed tx nose fx w/o stablj", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21320", "type": "HCPCS" } ], "description": "Closed tx nose fx w/ stablj", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21325", "type": "HCPCS" } ], "description": "Open tx nose fx uncomplicatd", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21330", "type": "HCPCS" } ], "description": "Open tx nose fx w/skele fixj", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21335", "type": "HCPCS" } ], "description": "Open tx nose & septal fx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21336", "type": "HCPCS" } ], "description": "Open tx septal fx w/wo stabj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21337", "type": "HCPCS" } ], "description": "Closed tx septal&nose fx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21338", "type": "HCPCS" } ], "description": "Open nasoethmoid fx w/o fixj", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21339", "type": "HCPCS" } ], "description": "Open nasoethmoid fx w/ fixj", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21340", "type": "HCPCS" } ], "description": "Perq tx nasoethmoid fx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21343", "type": "HCPCS" } ], "description": "Open tx dprsd front sinus fx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21344", "type": "HCPCS" } ], "description": "Open tx compl front sinus fx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21345", "type": "HCPCS" } ], "description": "Closed tx nose/jaw fx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21346", "type": "HCPCS" } ], "description": "Opn tx nasomax fx w/fixj", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21347", "type": "HCPCS" } ], "description": "Opn tx nasomax fx multple", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21348", "type": "HCPCS" } ], "description": "Opn tx nasomax fx w/graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21355", "type": "HCPCS" } ], "description": "Perq tx malar fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21356", "type": "HCPCS" } ], "description": "Opn tx dprsd zygomatic arch", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21360", "type": "HCPCS" } ], "description": "Opn tx dprsd malar fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21365", "type": "HCPCS" } ], "description": "Opn tx complx malar fx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21366", "type": "HCPCS" } ], "description": "Opn tx complx malar w/grft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21385", "type": "HCPCS" } ], "description": "Opn tx orbit fx transantral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21386", "type": "HCPCS" } ], "description": "Opn tx orbit fx periorbital", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21387", "type": "HCPCS" } ], "description": "Opn tx orbit fx combined", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21390", "type": "HCPCS" } ], "description": "Opn tx orbit periorbtl implt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21395", "type": "HCPCS" } ], "description": "Opn tx orbit periorbt w/grft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21400", "type": "HCPCS" } ], "description": "Closed tx orbit w/o manipulj", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21401", "type": "HCPCS" } ], "description": "Closed tx orbit w/manipulj", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21406", "type": "HCPCS" } ], "description": "Opn tx orbit fx w/o implant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21407", "type": "HCPCS" } ], "description": "Opn tx orbit fx w/implant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21408", "type": "HCPCS" } ], "description": "Opn tx orbit fx w/bone grft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21421", "type": "HCPCS" } ], "description": "Treat mouth roof fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21422", "type": "HCPCS" } ], "description": "Treat mouth roof fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21423", "type": "HCPCS" } ], "description": "Treat mouth roof fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21431", "type": "HCPCS" } ], "description": "Treat craniofacial fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21432", "type": "HCPCS" } ], "description": "Treat craniofacial fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21433", "type": "HCPCS" } ], "description": "Treat craniofacial fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21435", "type": "HCPCS" } ], "description": "Treat craniofacial fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21436", "type": "HCPCS" } ], "description": "Treat craniofacial fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21440", "type": "HCPCS" } ], "description": "Treat dental ridge fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21445", "type": "HCPCS" } ], "description": "Treat dental ridge fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21450", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21451", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21452", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21453", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21454", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21461", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21462", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21465", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21470", "type": "HCPCS" } ], "description": "Treat lower jaw fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21480", "type": "HCPCS" } ], "description": "Reset dislocated jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21485", "type": "HCPCS" } ], "description": "Reset dislocated jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21490", "type": "HCPCS" } ], "description": "Repair dislocated jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3280", "type": "HCPCS" } ], "description": "Thiethylperazine maleate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 12.28, "minimum": 12.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J3302", "type": "HCPCS" } ], "description": "Triamcinolone diacetate inj", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21497", "type": "HCPCS" } ], "description": "Interdental wiring", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21499", "type": "HCPCS" } ], "description": "Head surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21501", "type": "HCPCS" } ], "description": "Drain neck/chest lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21502", "type": "HCPCS" } ], "description": "Drain chest lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21510", "type": "HCPCS" } ], "description": "Drainage of bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21550", "type": "HCPCS" } ], "description": "Biopsy of neck/chest", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21552", "type": "HCPCS" } ], "description": "Exc neck les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21554", "type": "HCPCS" } ], "description": "Exc neck tum deep 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21555", "type": "HCPCS" } ], "description": "Exc neck les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21556", "type": "HCPCS" } ], "description": "Exc neck tum deep < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21557", "type": "HCPCS" } ], "description": "Resect neck thorax tumor<5cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21558", "type": "HCPCS" } ], "description": "Resect neck tumor 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21600", "type": "HCPCS" } ], "description": "Partial removal of rib", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21601", "type": "HCPCS" } ], "description": "Exc chest wall tumor w/ribs", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21602", "type": "HCPCS" } ], "description": "Exc ch wal tum w/o lymphadec", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21603", "type": "HCPCS" } ], "description": "Exc ch wal tum w/lymphadec", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21610", "type": "HCPCS" } ], "description": "Partial removal of rib", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21615", "type": "HCPCS" } ], "description": "Removal of rib", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21616", "type": "HCPCS" } ], "description": "Removal of rib and nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21620", "type": "HCPCS" } ], "description": "Partial removal of sternum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21627", "type": "HCPCS" } ], "description": "Sternal debridement", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21630", "type": "HCPCS" } ], "description": "Extensive sternum surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21632", "type": "HCPCS" } ], "description": "Extensive sternum surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21685", "type": "HCPCS" } ], "description": "Hyoid myotomy & suspension", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21700", "type": "HCPCS" } ], "description": "Revision of neck muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21705", "type": "HCPCS" } ], "description": "Revision of neck muscle/rib", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21720", "type": "HCPCS" } ], "description": "Revision of neck muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21725", "type": "HCPCS" } ], "description": "Revision of neck muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21740", "type": "HCPCS" } ], "description": "Reconstruction of sternum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21742", "type": "HCPCS" } ], "description": "Repair stern/nuss w/o scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21743", "type": "HCPCS" } ], "description": "Repair sternum/nuss w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21750", "type": "HCPCS" } ], "description": "Repair of sternum separation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21811", "type": "HCPCS" } ], "description": "Optx of rib fx w/fixj scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21812", "type": "HCPCS" } ], "description": "Treatment of rib fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21813", "type": "HCPCS" } ], "description": "Treatment of rib fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21820", "type": "HCPCS" } ], "description": "Treat sternum fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21825", "type": "HCPCS" } ], "description": "Treat sternum fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21899", "type": "HCPCS" } ], "description": "Neck/chest surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21920", "type": "HCPCS" } ], "description": "Biopsy soft tissue of back", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21925", "type": "HCPCS" } ], "description": "Biopsy soft tissue of back", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21930", "type": "HCPCS" } ], "description": "Exc back les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21931", "type": "HCPCS" } ], "description": "Exc back les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21932", "type": "HCPCS" } ], "description": "Exc back tum deep < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21933", "type": "HCPCS" } ], "description": "Exc back tum deep 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21935", "type": "HCPCS" } ], "description": "Resect back tum < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "21936", "type": "HCPCS" } ], "description": "Resect back tum 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22010", "type": "HCPCS" } ], "description": "I&d p-spine c/t/cerv-thor", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22015", "type": "HCPCS" } ], "description": "I&d abscess p-spine l/s/ls", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22100", "type": "HCPCS" } ], "description": "Remove part of neck vertebra", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22101", "type": "HCPCS" } ], "description": "Remove part thorax vertebra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22102", "type": "HCPCS" } ], "description": "Remove part lumbar vertebra", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22110", "type": "HCPCS" } ], "description": "Remove part of neck vertebra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22112", "type": "HCPCS" } ], "description": "Remove part thorax vertebra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22114", "type": "HCPCS" } ], "description": "Remove part lumbar vertebra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22116", "type": "HCPCS" } ], "description": "Remove extra spine segment", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22206", "type": "HCPCS" } ], "description": "Incis spine 3 column thorac", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22207", "type": "HCPCS" } ], "description": "Incis spine 3 column lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22208", "type": "HCPCS" } ], "description": "Incis spine 3 column adl seg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22210", "type": "HCPCS" } ], "description": "Incis 1 vertebral seg cerv", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22212", "type": "HCPCS" } ], "description": "Incis 1 vertebral seg thorac", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22214", "type": "HCPCS" } ], "description": "Incis 1 vertebral seg lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22216", "type": "HCPCS" } ], "description": "Incis addl spine segment", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22220", "type": "HCPCS" } ], "description": "Incis w/discectomy cervical", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22222", "type": "HCPCS" } ], "description": "Incis w/discectomy thoracic", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22224", "type": "HCPCS" } ], "description": "Incis w/discectomy lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22226", "type": "HCPCS" } ], "description": "Revise extra spine segment", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22310", "type": "HCPCS" } ], "description": "Closed tx vert fx w/o manj", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22315", "type": "HCPCS" } ], "description": "Closed tx vert fx w/manj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22318", "type": "HCPCS" } ], "description": "Treat odontoid fx w/o graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22319", "type": "HCPCS" } ], "description": "Treat odontoid fx w/graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22325", "type": "HCPCS" } ], "description": "Treat spine fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22326", "type": "HCPCS" } ], "description": "Treat neck spine fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22327", "type": "HCPCS" } ], "description": "Treat thorax spine fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22328", "type": "HCPCS" } ], "description": "Treat each add spine fx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22505", "type": "HCPCS" } ], "description": "Manipulation of spine", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22510", "type": "HCPCS" } ], "description": "Perq cervicothoracic inject", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22511", "type": "HCPCS" } ], "description": "Perq lumbosacral injection", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22513", "type": "HCPCS" } ], "description": "Perq vertebral augmentation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22514", "type": "HCPCS" } ], "description": "Perq vertebral augmentation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22526", "type": "HCPCS" } ], "description": "Idet single level", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22527", "type": "HCPCS" } ], "description": "Idet 1 or more levels", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22532", "type": "HCPCS" } ], "description": "Lat thorax spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22533", "type": "HCPCS" } ], "description": "Lat lumbar spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22534", "type": "HCPCS" } ], "description": "Lat thor/lumb addl seg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22548", "type": "HCPCS" } ], "description": "Neck spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22551", "type": "HCPCS" } ], "description": "Neck spine fuse&remov bel c2", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22554", "type": "HCPCS" } ], "description": "Neck spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22556", "type": "HCPCS" } ], "description": "Thorax spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 16906.49, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22558", "type": "HCPCS" } ], "description": "Lumbar spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 26163.21, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26163.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22586", "type": "HCPCS" } ], "description": "Prescrl fuse w/ instr l5-s1", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22590", "type": "HCPCS" } ], "description": "Spine & skull spinal fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22595", "type": "HCPCS" } ], "description": "Neck spinal fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22600", "type": "HCPCS" } ], "description": "Neck spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22610", "type": "HCPCS" } ], "description": "Thorax spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22612", "type": "HCPCS" } ], "description": "Lumbar spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22630", "type": "HCPCS" } ], "description": "Lumbar spine fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 26163.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26163.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22632", "type": "HCPCS" } ], "description": "Spine fusion extra segment", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22633", "type": "HCPCS" } ], "description": "Lumbar spine fusion combined", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 26163.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26163.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22800", "type": "HCPCS" } ], "description": "Post fusion <=6 vert seg", "standard_charges": [ { "billing_class": "facility", "maximum": 16906.49, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22802", "type": "HCPCS" } ], "description": "Post fusion 7-12 vert seg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22804", "type": "HCPCS" } ], "description": "Post fusion 13/> vert seg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22808", "type": "HCPCS" } ], "description": "Ant fusion 2-3 vert seg", "standard_charges": [ { "billing_class": "facility", "maximum": 16906.49, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22810", "type": "HCPCS" } ], "description": "Ant fusion 4-7 vert seg", "standard_charges": [ { "billing_class": "facility", "maximum": 16906.49, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22812", "type": "HCPCS" } ], "description": "Ant fusion 8/> vert seg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22818", "type": "HCPCS" } ], "description": "Kyphectomy 1-2 segments", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22819", "type": "HCPCS" } ], "description": "Kyphectomy 3 or more", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22830", "type": "HCPCS" } ], "description": "Exploration of spinal fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22841", "type": "HCPCS" } ], "description": "Insert spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22843", "type": "HCPCS" } ], "description": "Insert spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22844", "type": "HCPCS" } ], "description": "Insert spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22846", "type": "HCPCS" } ], "description": "Insert spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22847", "type": "HCPCS" } ], "description": "Insert spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22848", "type": "HCPCS" } ], "description": "Insert pelv fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22849", "type": "HCPCS" } ], "description": "Reinsert spinal fixation", "standard_charges": [ { "billing_class": "facility", "maximum": 12379.34, "minimum": 9206.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22850", "type": "HCPCS" } ], "description": "Remove spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22852", "type": "HCPCS" } ], "description": "Remove spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22855", "type": "HCPCS" } ], "description": "Remove spine fixation device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22856", "type": "HCPCS" } ], "description": "Cerv artific diskectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22857", "type": "HCPCS" } ], "description": "Lumbar Artif Diskectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22860", "type": "HCPCS" } ], "description": "Tot disc arthrp 2ntrspc lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22861", "type": "HCPCS" } ], "description": "Revise cerv artific disc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22862", "type": "HCPCS" } ], "description": "Revise Lumbar Artif Disc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22864", "type": "HCPCS" } ], "description": "Remove cerv artif disc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22865", "type": "HCPCS" } ], "description": "Remove Lumb Artif Disc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22867", "type": "HCPCS" } ], "description": "Insj stablj dev w/dcmprn", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22869", "type": "HCPCS" } ], "description": "Insj stablj dev w/o dcmprn", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22899", "type": "HCPCS" } ], "description": "Spine surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22900", "type": "HCPCS" } ], "description": "Exc abdl tum deep < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7306", "type": "HCPCS" } ], "description": "Levonorgestrel implant sys", "standard_charges": [ { "billing_class": "facility", "maximum": 1018.61, "minimum": 1018.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1018.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1018.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22901", "type": "HCPCS" } ], "description": "Exc abdl tum deep 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22902", "type": "HCPCS" } ], "description": "Exc abd les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22903", "type": "HCPCS" } ], "description": "Exc abd les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22904", "type": "HCPCS" } ], "description": "Radical resect abd tumor<5cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22905", "type": "HCPCS" } ], "description": "Rad resect abd tumor 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "22999", "type": "HCPCS" } ], "description": "Abdomen surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23000", "type": "HCPCS" } ], "description": "Removal of calcium deposits", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23020", "type": "HCPCS" } ], "description": "Release shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23030", "type": "HCPCS" } ], "description": "Drain shoulder lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23031", "type": "HCPCS" } ], "description": "Drain shoulder bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23035", "type": "HCPCS" } ], "description": "Drain shoulder bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23040", "type": "HCPCS" } ], "description": "Exploratory shoulder surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23044", "type": "HCPCS" } ], "description": "Exploratory shoulder surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23065", "type": "HCPCS" } ], "description": "Biopsy shoulder tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23066", "type": "HCPCS" } ], "description": "Biopsy shoulder tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23071", "type": "HCPCS" } ], "description": "Exc shoulder les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23073", "type": "HCPCS" } ], "description": "Exc shoulder tum deep 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23075", "type": "HCPCS" } ], "description": "Exc shoulder les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23076", "type": "HCPCS" } ], "description": "Exc shoulder tum deep < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23077", "type": "HCPCS" } ], "description": "Resect shoulder tumor < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23078", "type": "HCPCS" } ], "description": "Resect shoulder tumor 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23100", "type": "HCPCS" } ], "description": "Biopsy of shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23101", "type": "HCPCS" } ], "description": "Shoulder joint surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23105", "type": "HCPCS" } ], "description": "Remove shoulder joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23106", "type": "HCPCS" } ], "description": "Incision of collarbone joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23107", "type": "HCPCS" } ], "description": "Explore treat shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23120", "type": "HCPCS" } ], "description": "Partial removal collar bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23125", "type": "HCPCS" } ], "description": "Removal of collar bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23130", "type": "HCPCS" } ], "description": "Remove shoulder bone part", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23140", "type": "HCPCS" } ], "description": "Removal of bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23145", "type": "HCPCS" } ], "description": "Removal of bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23146", "type": "HCPCS" } ], "description": "Removal of bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7352", "type": "HCPCS" } ], "description": "Afamelanotide implant, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 7786.72, "minimum": 2943.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2943.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7786.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7786.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7615", "type": "HCPCS" } ], "description": "Levalbuterol comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 5.26, "minimum": 5.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23150", "type": "HCPCS" } ], "description": "Removal of humerus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23155", "type": "HCPCS" } ], "description": "Removal of humerus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23156", "type": "HCPCS" } ], "description": "Removal of humerus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23170", "type": "HCPCS" } ], "description": "Remove collar bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23172", "type": "HCPCS" } ], "description": "Remove shoulder blade lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23174", "type": "HCPCS" } ], "description": "Remove humerus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23180", "type": "HCPCS" } ], "description": "Remove collar bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23182", "type": "HCPCS" } ], "description": "Remove shoulder blade lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23184", "type": "HCPCS" } ], "description": "Remove humerus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23190", "type": "HCPCS" } ], "description": "Partial removal of scapula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23195", "type": "HCPCS" } ], "description": "Removal of head of humerus", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23200", "type": "HCPCS" } ], "description": "Resect clavicle tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23210", "type": "HCPCS" } ], "description": "Resect scapula tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23220", "type": "HCPCS" } ], "description": "Resect prox humerus tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23330", "type": "HCPCS" } ], "description": "Remove shoulder foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23333", "type": "HCPCS" } ], "description": "Remove shoulder fb deep", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23334", "type": "HCPCS" } ], "description": "Shoulder prosthesis removal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23335", "type": "HCPCS" } ], "description": "Shoulder prosthesis removal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23395", "type": "HCPCS" } ], "description": "Muscle transfer shoulder/arm", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23397", "type": "HCPCS" } ], "description": "Muscle transfers", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23400", "type": "HCPCS" } ], "description": "Fixation of shoulder blade", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23405", "type": "HCPCS" } ], "description": "Incision of tendon & muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23406", "type": "HCPCS" } ], "description": "Incise tendon(s) & muscle(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23410", "type": "HCPCS" } ], "description": "Repair rotator cuff acute", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23412", "type": "HCPCS" } ], "description": "Repair rotator cuff chronic", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23415", "type": "HCPCS" } ], "description": "Release of shoulder ligament", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23420", "type": "HCPCS" } ], "description": "Repair of shoulder", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23430", "type": "HCPCS" } ], "description": "Repair biceps tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23440", "type": "HCPCS" } ], "description": "Remove/transplant tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23450", "type": "HCPCS" } ], "description": "Repair shoulder capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23455", "type": "HCPCS" } ], "description": "Repair shoulder capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23460", "type": "HCPCS" } ], "description": "Repair shoulder capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7632", "type": "HCPCS" } ], "description": "Cromolyn sodium comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 0.87, "minimum": 0.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 0.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 0.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7641", "type": "HCPCS" } ], "description": "Flunisolide comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 27.18, "minimum": 27.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7680", "type": "HCPCS" } ], "description": "Terbutaline sulf comp con", "standard_charges": [ { "billing_class": "facility", "maximum": 34.2, "minimum": 34.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7681", "type": "HCPCS" } ], "description": "Terbutaline sulf comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 34.2, "minimum": 34.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7683", "type": "HCPCS" } ], "description": "Triamcinolone comp con", "standard_charges": [ { "billing_class": "facility", "maximum": 12.28, "minimum": 12.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "J7685", "type": "HCPCS" } ], "description": "Tobramycin comp unit", "standard_charges": [ { "billing_class": "facility", "maximum": 156.91, "minimum": 156.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23462", "type": "HCPCS" } ], "description": "Repair shoulder capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23465", "type": "HCPCS" } ], "description": "Repair shoulder capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23466", "type": "HCPCS" } ], "description": "Repair shoulder capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23470", "type": "HCPCS" } ], "description": "Reconstruct shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23472", "type": "HCPCS" } ], "description": "Reconstruct shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23473", "type": "HCPCS" } ], "description": "Revis reconst shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23474", "type": "HCPCS" } ], "description": "Revis reconst shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23480", "type": "HCPCS" } ], "description": "Revision of collar bone", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23485", "type": "HCPCS" } ], "description": "Revision of collar bone", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23490", "type": "HCPCS" } ], "description": "Reinforce clavicle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23491", "type": "HCPCS" } ], "description": "Reinforce shoulder bones", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23500", "type": "HCPCS" } ], "description": "Treat clavicle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23505", "type": "HCPCS" } ], "description": "Treat clavicle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23515", "type": "HCPCS" } ], "description": "Treat clavicle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23520", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23525", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23530", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23532", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23540", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23545", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23550", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23552", "type": "HCPCS" } ], "description": "Treat clavicle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23570", "type": "HCPCS" } ], "description": "Treat shoulder blade fx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23575", "type": "HCPCS" } ], "description": "Treat shoulder blade fx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23585", "type": "HCPCS" } ], "description": "Treat scapula fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23600", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23605", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23615", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23616", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23620", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23625", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23630", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23650", "type": "HCPCS" } ], "description": "Treat shoulder dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23655", "type": "HCPCS" } ], "description": "Treat shoulder dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23660", "type": "HCPCS" } ], "description": "Treat shoulder dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23665", "type": "HCPCS" } ], "description": "Treat dislocation/fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23670", "type": "HCPCS" } ], "description": "Treat dislocation/fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23675", "type": "HCPCS" } ], "description": "Treat dislocation/fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23680", "type": "HCPCS" } ], "description": "Treat dislocation/fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23700", "type": "HCPCS" } ], "description": "Fixation of shoulder", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23800", "type": "HCPCS" } ], "description": "Fusion of shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23802", "type": "HCPCS" } ], "description": "Fusion of shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23900", "type": "HCPCS" } ], "description": "Amputation of arm & girdle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23920", "type": "HCPCS" } ], "description": "Amputation at shoulder joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23921", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23929", "type": "HCPCS" } ], "description": "Shoulder surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23930", "type": "HCPCS" } ], "description": "Drainage of arm lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23931", "type": "HCPCS" } ], "description": "Drainage of arm bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "23935", "type": "HCPCS" } ], "description": "Drain arm/elbow bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24000", "type": "HCPCS" } ], "description": "Exploratory elbow surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24006", "type": "HCPCS" } ], "description": "Release elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24065", "type": "HCPCS" } ], "description": "Biopsy arm/elbow soft tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24066", "type": "HCPCS" } ], "description": "Biopsy arm/elbow soft tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24071", "type": "HCPCS" } ], "description": "Exc arm/elbow les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24073", "type": "HCPCS" } ], "description": "Ex arm/elbow tum deep 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24075", "type": "HCPCS" } ], "description": "Exc arm/elbow les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24076", "type": "HCPCS" } ], "description": "Ex arm/elbow tum deep < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24077", "type": "HCPCS" } ], "description": "Resect arm/elbow tum < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24079", "type": "HCPCS" } ], "description": "Resect arm/elbow tum 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24100", "type": "HCPCS" } ], "description": "Biopsy elbow joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24101", "type": "HCPCS" } ], "description": "Explore/treat elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24102", "type": "HCPCS" } ], "description": "Remove elbow joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24105", "type": "HCPCS" } ], "description": "Removal of elbow bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24110", "type": "HCPCS" } ], "description": "Remove humerus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24115", "type": "HCPCS" } ], "description": "Remove/graft bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24116", "type": "HCPCS" } ], "description": "Remove/graft bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24120", "type": "HCPCS" } ], "description": "Remove elbow lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24125", "type": "HCPCS" } ], "description": "Remove/graft bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24126", "type": "HCPCS" } ], "description": "Remove/graft bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24130", "type": "HCPCS" } ], "description": "Removal of head of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24134", "type": "HCPCS" } ], "description": "Removal of arm bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24136", "type": "HCPCS" } ], "description": "Remove radius bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24138", "type": "HCPCS" } ], "description": "Remove elbow bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24140", "type": "HCPCS" } ], "description": "Partial removal of arm bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24145", "type": "HCPCS" } ], "description": "Partial removal of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24147", "type": "HCPCS" } ], "description": "Partial removal of elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24149", "type": "HCPCS" } ], "description": "Radical resection of elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", 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"payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24200", "type": "HCPCS" } ], "description": "Removal of arm foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24201", "type": "HCPCS" } ], "description": "Removal of arm foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24300", "type": "HCPCS" } ], "description": "Manipulate elbow w/anesth", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24301", "type": "HCPCS" } ], "description": "Muscle/tendon transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24305", "type": "HCPCS" } ], "description": "Arm tendon lengthening", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24310", "type": "HCPCS" } ], "description": "Revision of arm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24320", "type": "HCPCS" } ], "description": "Repair of arm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24330", "type": "HCPCS" } ], "description": "Revision of arm muscles", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24331", "type": "HCPCS" } ], "description": "Revision of arm muscles", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24332", "type": "HCPCS" } ], "description": "Tenolysis triceps", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24340", "type": "HCPCS" } ], "description": "Repair of biceps tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { 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"outpatient" } ] }, { "code_information": [ { "code": "24344", "type": "HCPCS" } ], "description": "Reconstruct elbow lat ligmnt", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24345", "type": "HCPCS" } ], "description": "Repr elbw med ligmnt w/tissu", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24346", "type": "HCPCS" } ], "description": "Reconstruct elbow med ligmnt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24357", "type": "HCPCS" } ], "description": "Repair elbow perc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24358", "type": "HCPCS" } ], "description": "Repair elbow w/deb open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24359", "type": "HCPCS" } ], "description": "Repair elbow deb/attch open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24360", "type": "HCPCS" } ], "description": "Reconstruct elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24361", "type": "HCPCS" } ], "description": "Reconstruct elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24362", "type": "HCPCS" } ], "description": "Reconstruct elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24363", "type": "HCPCS" } ], "description": "Replace elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24365", "type": "HCPCS" } ], "description": "Reconstruct head of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24366", "type": "HCPCS" } ], "description": "Reconstruct head of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24370", "type": "HCPCS" } ], "description": "Revise reconst elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24371", "type": "HCPCS" } ], "description": "Revise reconst elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24400", "type": "HCPCS" } ], "description": "Revision of humerus", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24410", "type": "HCPCS" } ], "description": "Revision of humerus", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24420", "type": "HCPCS" } ], "description": "Revision of humerus", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24430", "type": "HCPCS" } ], "description": "Repair of humerus", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24435", "type": "HCPCS" } ], "description": "Repair humerus with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24470", "type": "HCPCS" } ], "description": "Revision of elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24495", "type": "HCPCS" } ], "description": "Decompression of forearm", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24498", "type": "HCPCS" } ], "description": "Reinforce humerus", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24500", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24505", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24515", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24516", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24530", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24535", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24538", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24545", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24546", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24560", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24565", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24566", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24575", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24576", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24577", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24579", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24582", "type": "HCPCS" } ], "description": "Treat humerus fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24586", "type": "HCPCS" } ], "description": "Treat elbow fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24587", "type": "HCPCS" } ], "description": "Treat elbow fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24600", "type": "HCPCS" } ], "description": "Treat elbow dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24605", "type": "HCPCS" } ], "description": "Treat elbow dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24615", "type": "HCPCS" } ], "description": "Treat elbow dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24620", "type": "HCPCS" } ], "description": "Treat elbow fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24635", "type": "HCPCS" } ], "description": "Treat elbow fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24640", "type": "HCPCS" } ], "description": "Treat elbow dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24650", "type": "HCPCS" } ], "description": "Treat radius fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24655", "type": "HCPCS" } ], "description": "Treat radius fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24665", "type": "HCPCS" } ], "description": "Treat radius fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24666", "type": "HCPCS" } ], "description": "Treat radius fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24670", "type": "HCPCS" } ], "description": "Treat ulnar fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24675", "type": "HCPCS" } ], "description": "Treat ulnar fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24685", "type": "HCPCS" } ], "description": "Treat ulnar fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24800", "type": "HCPCS" } ], "description": "Fusion of elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24802", "type": "HCPCS" } ], "description": "Fusion/graft of elbow joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24900", "type": "HCPCS" } ], "description": "Amputation of upper arm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24920", "type": "HCPCS" } ], "description": "Amputation of upper arm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24925", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24930", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24931", "type": "HCPCS" } ], "description": "Amputate upper arm & implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24935", "type": "HCPCS" } ], "description": "Revision of amputation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24940", "type": "HCPCS" } ], "description": "Revision of upper arm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "24999", "type": "HCPCS" } ], "description": "Upper arm/elbow surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25000", "type": "HCPCS" } ], "description": "Incision of tendon sheath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25001", "type": "HCPCS" } ], "description": "Incise flexor carpi radialis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25020", "type": "HCPCS" } ], "description": "Decompress forearm 1 space", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25023", "type": "HCPCS" } ], "description": "Decompress forearm 1 space", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25024", "type": "HCPCS" } ], "description": "Decompress forearm 2 spaces", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25025", "type": "HCPCS" } ], "description": "Decompress forearm 2 spaces", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25028", "type": "HCPCS" } ], "description": "Drainage of forearm lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25031", "type": "HCPCS" } ], "description": "Drainage of forearm bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25035", "type": "HCPCS" } ], "description": "Treat forearm bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25040", "type": "HCPCS" } ], "description": "Explore/treat wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25065", "type": "HCPCS" } ], "description": "Biopsy forearm soft tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25066", "type": "HCPCS" } ], "description": "Biopsy forearm soft tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25071", "type": "HCPCS" } ], "description": "Exc forearm les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25073", "type": "HCPCS" } ], "description": "Exc forearm tum deep 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25075", "type": "HCPCS" } ], "description": "Exc forearm les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25076", "type": "HCPCS" } ], "description": "Exc forearm tum deep < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25077", "type": "HCPCS" } ], "description": "Resect forearm/wrist tum<3cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25078", "type": "HCPCS" } ], "description": "Resect forarm/wrist tum 3cm>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25085", "type": "HCPCS" } ], "description": "Incision of wrist capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25100", "type": "HCPCS" } ], "description": "Biopsy of wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25101", "type": "HCPCS" } ], "description": "Explore/treat wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25105", "type": "HCPCS" } ], "description": "Remove wrist joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25107", "type": "HCPCS" } ], "description": "Remove wrist joint cartilage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25109", "type": "HCPCS" } ], "description": "Excise tendon forearm/wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25110", "type": "HCPCS" } ], "description": "Remove wrist tendon lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25111", "type": "HCPCS" } ], "description": "Remove wrist tendon lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25112", "type": "HCPCS" } ], "description": "Reremove wrist tendon lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25115", "type": "HCPCS" } ], "description": "Remove wrist/forearm lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25116", "type": "HCPCS" } ], "description": "Remove wrist/forearm lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25118", "type": "HCPCS" } ], "description": "Excise wrist tendon sheath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25119", "type": "HCPCS" } ], "description": "Partial removal of ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25120", "type": "HCPCS" } ], "description": "Removal of forearm lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25125", "type": "HCPCS" } ], "description": "Remove/graft forearm lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25126", "type": "HCPCS" } ], "description": "Remove/graft forearm lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25130", "type": "HCPCS" } ], "description": "Removal of wrist lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25135", "type": "HCPCS" } ], "description": "Remove & graft wrist lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25136", "type": "HCPCS" } ], "description": "Remove & graft wrist lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25145", "type": "HCPCS" } ], "description": "Remove forearm bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25150", "type": "HCPCS" } ], "description": "Partial removal of ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25151", "type": "HCPCS" } ], "description": "Partial removal of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25170", "type": "HCPCS" } ], "description": "Resect radius/ulnar tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25210", "type": "HCPCS" } ], "description": "Removal of wrist bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25215", "type": "HCPCS" } ], "description": "Removal of wrist bones", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25230", "type": "HCPCS" } ], "description": "Partial removal of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25240", "type": "HCPCS" } ], "description": "Partial removal of ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25248", "type": "HCPCS" } ], "description": "Remove forearm foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25250", "type": "HCPCS" } ], "description": "Removal of wrist prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25251", "type": "HCPCS" } ], "description": "Removal of wrist prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25259", "type": "HCPCS" } ], "description": "Manipulate wrist w/anesthes", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25260", "type": "HCPCS" } ], "description": "Repair forearm tendon/muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25263", "type": "HCPCS" } ], "description": "Repair forearm tendon/muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25265", "type": "HCPCS" } ], "description": "Repair forearm tendon/muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25270", "type": "HCPCS" } ], "description": "Repair forearm tendon/muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25272", "type": "HCPCS" } ], "description": "Repair forearm tendon/muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25274", "type": "HCPCS" } ], "description": "Repair forearm tendon/muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25275", "type": "HCPCS" } ], "description": "Repair forearm tendon sheath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25280", "type": "HCPCS" } ], "description": "Revise wrist/forearm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25290", "type": "HCPCS" } ], "description": "Incise wrist/forearm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25295", "type": "HCPCS" } ], "description": "Release wrist/forearm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25300", "type": "HCPCS" } ], "description": "Fusion of tendons at wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25301", "type": "HCPCS" } ], "description": "Fusion of tendons at wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25310", "type": "HCPCS" } ], "description": "Transplant forearm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25312", "type": "HCPCS" } ], "description": "Transplant forearm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25315", "type": "HCPCS" } ], "description": "Revise palsy hand tendon(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25316", "type": "HCPCS" } ], "description": "Revise palsy hand tendon(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25320", "type": "HCPCS" } ], "description": "Repair/revise wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25332", "type": "HCPCS" } ], "description": "Revise wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25335", "type": "HCPCS" } ], "description": "Realignment of hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25337", "type": "HCPCS" } ], "description": "Reconstruct ulna/radioulnar", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25350", "type": "HCPCS" } ], "description": "Revision of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25355", "type": "HCPCS" } ], "description": "Revision of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25360", "type": "HCPCS" } ], "description": "Revision of ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25365", "type": "HCPCS" } ], "description": "Revise radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25370", "type": "HCPCS" } ], "description": "Revise radius or ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25375", "type": "HCPCS" } ], "description": "Revise radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25390", "type": "HCPCS" } ], "description": "Shorten radius or ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25391", "type": "HCPCS" } ], "description": "Lengthen radius or ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25392", "type": "HCPCS" } ], "description": "Shorten radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25393", "type": "HCPCS" } ], "description": "Lengthen radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25394", "type": "HCPCS" } ], "description": "Repair carpal bone shorten", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25400", "type": "HCPCS" } ], "description": "Repair radius or ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25405", "type": "HCPCS" } ], "description": "Repair/graft radius or ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25415", "type": "HCPCS" } ], "description": "Repair radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25420", "type": "HCPCS" } ], "description": "Repair/graft radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25425", "type": "HCPCS" } ], "description": "Repair/graft radius or ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25426", "type": "HCPCS" } ], "description": "Repair/graft radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25430", "type": "HCPCS" } ], "description": "Vasc graft into carpal bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25431", "type": "HCPCS" } ], "description": "Repair nonunion carpal bone", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25440", "type": "HCPCS" } ], "description": "Repair/graft wrist bone", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25441", "type": "HCPCS" } ], "description": "Reconstruct wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25442", "type": "HCPCS" } ], "description": "Reconstruct wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25443", "type": "HCPCS" } ], "description": "Reconstruct wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25444", "type": "HCPCS" } ], "description": "Reconstruct wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25445", "type": "HCPCS" } ], "description": "Reconstruct wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25446", "type": "HCPCS" } ], "description": "Wrist replacement", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25447", "type": "HCPCS" } ], "description": "Repair wrist joints", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25449", "type": "HCPCS" } ], "description": "Remove wrist joint implant", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25450", "type": "HCPCS" } ], "description": "Revision of wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25455", "type": "HCPCS" } ], "description": "Revision of wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25490", "type": "HCPCS" } ], "description": "Reinforce radius", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25491", "type": "HCPCS" } ], "description": "Reinforce ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25492", "type": "HCPCS" } ], "description": "Reinforce radius and ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25500", "type": "HCPCS" } ], "description": "Treat fracture of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25505", "type": "HCPCS" } ], "description": "Treat fracture of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25515", "type": "HCPCS" } ], "description": "Treat fracture of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25520", "type": "HCPCS" } ], "description": "Treat fracture of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25525", "type": "HCPCS" } ], "description": "Treat fracture of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25526", "type": "HCPCS" } ], "description": "Treat fracture of radius", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25530", "type": "HCPCS" } ], "description": "Treat fracture of ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25535", "type": "HCPCS" } ], "description": "Treat fracture of ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25545", "type": "HCPCS" } ], "description": "Treat fracture of ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25560", "type": "HCPCS" } ], "description": "Treat fracture radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25565", "type": "HCPCS" } ], "description": "Treat fracture radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25574", "type": "HCPCS" } ], "description": "Treat fracture radius & ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25575", "type": "HCPCS" } ], "description": "Treat fracture radius/ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25600", "type": "HCPCS" } ], "description": "Treat fracture radius/ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25605", "type": "HCPCS" } ], "description": "Treat fracture radius/ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25606", "type": "HCPCS" } ], "description": "Treat Fx Distal Radial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25607", "type": "HCPCS" } ], "description": "Treat Fx Rad Extra-Articul", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25608", "type": "HCPCS" } ], "description": "Treat Fx Rad Intra-Articul", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25609", "type": "HCPCS" } ], "description": "Treat Fx Radial 3+ Frag", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25622", "type": "HCPCS" } ], "description": "Treat wrist bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25624", "type": "HCPCS" } ], "description": "Treat wrist bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25628", "type": "HCPCS" } ], "description": "Treat wrist bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25630", "type": "HCPCS" } ], "description": "Treat wrist bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25635", "type": "HCPCS" } ], "description": "Treat wrist bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25645", "type": "HCPCS" } ], "description": "Treat wrist bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25650", "type": "HCPCS" } ], "description": "Treat wrist bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25651", "type": "HCPCS" } ], "description": "Pin ulnar styloid fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25652", "type": "HCPCS" } ], "description": "Treat fracture ulnar styloid", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25660", "type": "HCPCS" } ], "description": "Treat wrist dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25670", "type": "HCPCS" } ], "description": "Treat wrist dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25671", "type": "HCPCS" } ], "description": "Pin radioulnar dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25675", "type": "HCPCS" } ], "description": "Treat wrist dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25676", "type": "HCPCS" } ], "description": "Treat wrist dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25680", "type": "HCPCS" } ], "description": "Treat wrist fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25685", "type": "HCPCS" } ], "description": "Treat wrist fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25690", "type": "HCPCS" } ], "description": "Treat wrist dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25695", "type": "HCPCS" } ], "description": "Treat wrist dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25800", "type": "HCPCS" } ], "description": "Fusion of wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25805", "type": "HCPCS" } ], "description": "Fusion/graft of wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25810", "type": "HCPCS" } ], "description": "Fusion/graft of wrist joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25820", "type": "HCPCS" } ], "description": "Fusion of hand bones", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25825", "type": "HCPCS" } ], "description": "Fuse hand bones with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25830", "type": "HCPCS" } ], "description": "Fusion radioulnar jnt/ulna", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25900", "type": "HCPCS" } ], "description": "Amputation of forearm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25905", "type": "HCPCS" } ], "description": "Amputation of forearm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25907", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25909", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25915", "type": "HCPCS" } ], "description": "Amputation of forearm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25920", "type": "HCPCS" } ], "description": "Amputate hand at wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25922", "type": "HCPCS" } ], "description": "Amputate hand at wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25924", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25927", "type": "HCPCS" } ], "description": "Amputation of hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25929", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25931", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "25999", "type": "HCPCS" } ], "description": "Forearm or wrist surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26010", "type": "HCPCS" } ], "description": "Drainage of finger abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26011", "type": "HCPCS" } ], "description": "Drainage of finger abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26020", "type": "HCPCS" } ], "description": "Drain hand tendon sheath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8607", "type": "HCPCS" } ], "description": "Inj vocal cord bulking agent", "standard_charges": [ { "billing_class": "facility", "maximum": 120.97, "minimum": 120.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 120.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 120.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0173", "type": "HCPCS" } ], "description": "Trimethobenzamide HCl 250mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.76, "minimum": 1.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0174", "type": "HCPCS" } ], "description": "Thiethylperazine maleate10mg", "standard_charges": [ { "billing_class": "facility", "maximum": 1.76, "minimum": 1.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26025", "type": "HCPCS" } ], "description": "Drainage of palm bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26030", "type": "HCPCS" } ], "description": "Drainage of palm bursas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26034", "type": "HCPCS" } ], "description": "Treat hand bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26035", "type": "HCPCS" } ], "description": "Decompress fingers/hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26037", "type": "HCPCS" } ], "description": "Decompress fingers/hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26040", "type": "HCPCS" } ], "description": "Release palm contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26045", "type": "HCPCS" } ], "description": "Release palm contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26055", "type": "HCPCS" } ], "description": "Incise finger tendon sheath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26060", "type": "HCPCS" } ], "description": "Incision of finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26070", "type": "HCPCS" } ], "description": "Explore/treat hand joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26075", "type": "HCPCS" } ], "description": "Explore/treat finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26080", "type": "HCPCS" } ], "description": "Explore/treat finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26100", "type": "HCPCS" } ], "description": "Biopsy hand joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26105", "type": "HCPCS" } ], "description": "Biopsy finger joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26110", "type": "HCPCS" } ], "description": "Biopsy finger joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26111", "type": "HCPCS" } ], "description": "Exc hand les sc 1.5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26113", "type": "HCPCS" } ], "description": "Exc hand tum deep 1.5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26115", "type": "HCPCS" } ], "description": "Exc hand les sc < 1.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26116", "type": "HCPCS" } ], "description": "Exc hand tum deep < 1.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26117", "type": "HCPCS" } ], "description": "Rad resect hand tumor < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26118", "type": "HCPCS" } ], "description": "Rad resect hand tumor 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26121", "type": "HCPCS" } ], "description": "Release palm contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26123", "type": "HCPCS" } ], "description": "Release palm contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26130", "type": "HCPCS" } ], "description": "Remove wrist joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26135", "type": "HCPCS" } ], "description": "Revise finger joint each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26140", "type": "HCPCS" } ], "description": "Revise finger joint each", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26145", "type": "HCPCS" } ], "description": "Tendon excision palm/finger", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26160", "type": "HCPCS" } ], "description": "Remove tendon sheath lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26170", "type": "HCPCS" } ], "description": "Removal of palm tendon each", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26180", "type": "HCPCS" } ], "description": "Removal of finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26185", "type": "HCPCS" } ], "description": "Remove finger bone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26200", "type": "HCPCS" } ], "description": "Remove hand bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q2026", "type": "HCPCS" } ], "description": "Radiesse injection", "standard_charges": [ { "billing_class": "facility", "maximum": 903.57, "minimum": 349.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 349.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 903.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 903.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q3001", "type": "HCPCS" } ], "description": "Brachytherapy radioelements", "standard_charges": [ { "billing_class": "facility", "maximum": 162.17, "minimum": 162.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 162.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 162.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4101", "type": "HCPCS" } ], "description": "Apligraf", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 51.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 51.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4102", "type": "HCPCS" } ], "description": "Oasis wound matrix", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 20.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 20.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4103", "type": "HCPCS" } ], "description": "Oasis burn matrix", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 21.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 21.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4104", "type": "HCPCS" } ], "description": "Integra bmwd", "standard_charges": [ { "billing_class": "facility", "maximum": 142.0, "minimum": 89.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 89.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 142.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 142.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4105", "type": "HCPCS" } ], "description": "Integra drt or omnigraft", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 51.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 51.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4106", "type": "HCPCS" } ], "description": "Dermagraft", "standard_charges": [ { "billing_class": "facility", "maximum": 138.05, "minimum": 138.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 138.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 138.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26205", "type": "HCPCS" } ], "description": "Remove/graft bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26210", "type": "HCPCS" } ], "description": "Removal of finger lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26215", "type": "HCPCS" } ], "description": "Remove/graft finger lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26230", "type": "HCPCS" } ], "description": "Partial removal of hand bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26235", "type": "HCPCS" } ], "description": "Partial removal finger bone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26236", "type": "HCPCS" } ], "description": "Partial removal finger bone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26250", "type": "HCPCS" } ], "description": "Extensive hand surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26260", "type": "HCPCS" } ], "description": "Resect prox finger tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26262", "type": "HCPCS" } ], "description": "Resect distal finger tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26320", "type": "HCPCS" } ], "description": "Removal of implant from hand", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26340", "type": "HCPCS" } ], "description": "Manipulate finger w/anesth", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26341", "type": "HCPCS" } ], "description": "Manipulat palm cord post inj", "standard_charges": [ { "billing_class": 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Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26370", "type": "HCPCS" } ], "description": "Repair finger/hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26372", "type": "HCPCS" } ], "description": "Repair/graft hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, 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"Revise hand/finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26392", "type": "HCPCS" } ], "description": "Repair/graft hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26410", "type": "HCPCS" } ], "description": "Repair hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26412", "type": "HCPCS" } ], "description": "Repair/graft hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26415", "type": "HCPCS" } ], "description": "Excision hand/finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26416", "type": "HCPCS" } ], "description": "Graft hand or finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26418", "type": "HCPCS" } ], "description": "Repair finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26420", "type": "HCPCS" } ], "description": "Repair/graft finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26426", "type": "HCPCS" } ], "description": "Repair finger/hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26428", "type": "HCPCS" } ], "description": "Repair/graft finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26432", "type": "HCPCS" } ], "description": "Repair finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26433", "type": "HCPCS" } ], "description": "Repair finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4108", "type": "HCPCS" } ], "description": "Integra matrix", "standard_charges": [ { "billing_class": "facility", "maximum": 121.52, "minimum": 76.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 76.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 121.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 121.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4110", "type": "HCPCS" } ], "description": "Primatrix", "standard_charges": [ { "billing_class": "facility", "maximum": 177.26, "minimum": 111.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 111.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 177.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 177.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4111", "type": "HCPCS" } ], "description": "Gammagraft", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 12.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 12.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4114", "type": "HCPCS" } ], "description": "Integra flowable wound matri", "standard_charges": [ { "billing_class": "facility", "maximum": 4337.65, "minimum": 2721.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2721.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4337.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4337.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4115", "type": "HCPCS" } ], "description": "Alloskin", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 25.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 25.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4118", "type": "HCPCS" } ], "description": "Matristem micromatrix", "standard_charges": [ { "billing_class": "facility", "maximum": 6.88, "minimum": 4.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4121", "type": "HCPCS" } ], "description": "Theraskin", "standard_charges": [ { "billing_class": "facility", "maximum": 131.3, "minimum": 82.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 82.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4124", "type": "HCPCS" } ], "description": "Oasis tri-layer wound matrix", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 17.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 17.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4126", "type": "HCPCS" } ], "description": "Memoderm/derma/tranz/integup", "standard_charges": [ { "billing_class": "facility", "maximum": 161.35, "minimum": 101.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 101.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 161.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 161.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4127", "type": "HCPCS" } ], "description": "Talymed", "standard_charges": [ { "billing_class": "facility", "maximum": 185.61, "minimum": 116.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 116.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 185.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 185.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4128", "type": "HCPCS" } ], "description": "Flexhd/allopatchhd/matrixhd", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 52.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 52.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4132", "type": "HCPCS" } ], "description": "Grafix core", "standard_charges": [ { "billing_class": "facility", "maximum": 370.86, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 232.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 370.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 370.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26434", "type": "HCPCS" } ], "description": "Repair/graft finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26437", "type": "HCPCS" } ], "description": "Realignment of tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26440", "type": "HCPCS" } ], "description": "Release palm/finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26442", "type": "HCPCS" } ], "description": "Release palm & finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26445", "type": "HCPCS" } ], "description": "Release hand/finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26449", "type": "HCPCS" } ], "description": "Release forearm/hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26450", "type": "HCPCS" } ], "description": "Incision of palm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26455", "type": "HCPCS" } ], "description": "Incision of finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26460", "type": "HCPCS" } ], "description": "Incise hand/finger tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26471", "type": "HCPCS" } ], "description": "Fusion of finger tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26474", "type": "HCPCS" } ], "description": "Fusion of finger tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26476", "type": "HCPCS" } ], "description": "Tendon lengthening", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26477", "type": "HCPCS" } ], "description": "Tendon shortening", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26478", "type": "HCPCS" } ], "description": "Lengthening of hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26479", "type": "HCPCS" } ], "description": "Shortening of hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26480", "type": "HCPCS" } ], "description": "Transplant hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26483", "type": "HCPCS" } ], "description": "Transplant/graft hand tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26485", "type": "HCPCS" } ], "description": "Transplant palm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26489", "type": "HCPCS" } ], "description": "Transplant/graft palm tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26490", "type": "HCPCS" } ], "description": "Revise thumb tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26492", "type": "HCPCS" } ], "description": "Tendon transfer with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26494", "type": "HCPCS" } ], "description": "Hand tendon/muscle transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26496", "type": "HCPCS" } ], "description": "Revise thumb tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26497", "type": "HCPCS" } ], "description": "Finger tendon transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26498", "type": "HCPCS" } ], "description": "Finger tendon transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26499", "type": "HCPCS" } ], "description": "Revision of finger", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26500", "type": "HCPCS" } ], "description": "Hand tendon reconstruction", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26502", "type": "HCPCS" } ], "description": "Hand tendon reconstruction", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26508", "type": "HCPCS" } ], "description": "Release thumb contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26510", "type": "HCPCS" } ], "description": "Thumb tendon transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26516", "type": "HCPCS" } ], "description": "Fusion of knuckle joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26517", "type": "HCPCS" } ], "description": "Fusion of knuckle joints", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4107", "type": "HCPCS" } ], "description": "Graftjacket", "standard_charges": [ { "billing_class": "facility", "maximum": 369.83, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 369.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 369.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4113", "type": "HCPCS" } ], "description": "Graftjacket xpress", "standard_charges": [ { "billing_class": "facility", "maximum": 5413.23, "minimum": 5413.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5413.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5413.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4117", "type": "HCPCS" } ], "description": "Hyalomatrix", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 81.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4122", "type": "HCPCS" } ], "description": "Dermacell", "standard_charges": [ { "billing_class": "facility", "maximum": 327.99, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 327.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 327.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4123", "type": "HCPCS" } ], "description": "Alloskin", "standard_charges": [ { "billing_class": "facility", "maximum": 216.2, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 216.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 216.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4133", "type": "HCPCS" } ], "description": "Grafix prime", "standard_charges": [ { "billing_class": "facility", "maximum": 376.01, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 235.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 376.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 376.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4137", "type": "HCPCS" } ], "description": "Amnioexcel or biodexcel, 1cm", "standard_charges": [ { "billing_class": "facility", "maximum": 316.2, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 198.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 316.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 316.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4138", "type": "HCPCS" } ], "description": "Biodfence dryflex, 1cm", "standard_charges": [ { "billing_class": "facility", "maximum": 253.57, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 159.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 253.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 253.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4140", "type": "HCPCS" } ], "description": "Biodfence 1cm", "standard_charges": [ { "billing_class": "facility", "maximum": 465.61, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 292.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 465.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 465.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4141", "type": "HCPCS" } ], "description": "Alloskin ac, 1 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 64.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 64.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4147", "type": "HCPCS" } ], "description": "Architect ecm px fx 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 4271.72, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4271.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4271.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4148", "type": "HCPCS" } ], "description": "Neox 1k, 1cm", "standard_charges": [ { "billing_class": "facility", "maximum": 345.55, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 216.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 345.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 345.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4149", "type": "HCPCS" } ], "description": "Excellagen, 0.1 cc", "standard_charges": [ { "billing_class": "facility", "maximum": 471.54, "minimum": 471.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 471.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 471.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4150", "type": "HCPCS" } ], "description": "Allowrap ds or dry 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 234.96, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 147.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 234.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 234.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4151", "type": "HCPCS" } ], "description": "Amnioband, guardian 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 388.67, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 243.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 388.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 388.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4152", "type": "HCPCS" } ], "description": "Dermapure 1 square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 141.06, "minimum": 88.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 88.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 141.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 141.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4153", "type": "HCPCS" } ], "description": "Dermavest, plurivest sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 630.64, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 395.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 630.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 630.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4154", "type": "HCPCS" } ], "description": "Biovance 1 square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 391.22, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 245.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 391.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 391.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4155", "type": "HCPCS" } ], "description": "Neoxflo or clarixflo 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 77.83, "minimum": 48.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 48.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4156", "type": "HCPCS" } ], "description": "Neox 100 1 square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 173.58, "minimum": 108.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 108.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 173.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 173.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4158", "type": "HCPCS" } ], "description": "Marigen 1 square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 204.5, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 128.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 204.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 204.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4159", "type": "HCPCS" } ], "description": "Affinity1 square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 713.68, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 447.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 713.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 713.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4160", "type": "HCPCS" } ], "description": "Nushield 1 square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 254.55, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 159.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 254.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 254.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4163", "type": "HCPCS" } ], "description": "Amnio bio and woundex sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 493.71, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 309.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 493.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 493.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4166", "type": "HCPCS" } ], "description": "Cytal, per square centimeter", "standard_charges": [ { "billing_class": "facility", "maximum": 119.99, "minimum": 34.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 34.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4171", "type": "HCPCS" } ], "description": "Interfyl, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 32.28, "minimum": 20.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 20.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4175", "type": "HCPCS" } ], "description": "Miroderm", "standard_charges": [ { "billing_class": "facility", "maximum": 187.1, "minimum": 117.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 117.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 187.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 187.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4178", "type": "HCPCS" } ], "description": "Floweramniopatch, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 236.26, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 148.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 236.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 236.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4184", "type": "HCPCS" } ], "description": "Cellesta, 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1691.96, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1061.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1691.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1691.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4186", "type": "HCPCS" } ], "description": "Epifix 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 429.07, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 269.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 429.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 429.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4187", "type": "HCPCS" } ], "description": "Epicord 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 657.8, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 412.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 657.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 657.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4188", "type": "HCPCS" } ], "description": "Amnioarmor 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 939.39, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 589.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 939.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 939.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4190", "type": "HCPCS" } ], "description": "Artacent ac 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 638.72, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 400.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 638.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 638.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4191", "type": "HCPCS" } ], "description": "Restorigin 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2754.2, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1727.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2754.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2754.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4194", "type": "HCPCS" } ], "description": "Novachor 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2327.67, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1460.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2327.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2327.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4195", "type": "HCPCS" } ], "description": "Puraply 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 278.56, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 174.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 278.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 278.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4196", "type": "HCPCS" } ], "description": "Puraply am 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 286.42, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 179.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 286.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 286.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4197", "type": "HCPCS" } ], "description": "Puraply xt 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 196.85, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 123.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 196.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 196.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4199", "type": "HCPCS" } ], "description": "Cygnus matrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 985.87, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 618.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 985.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 985.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4201", "type": "HCPCS" } ], "description": "Matrion 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 230.43, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 144.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 230.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 230.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4203", "type": "HCPCS" } ], "description": "Derma-gide, 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 813.49, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 510.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 813.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 813.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4157", "type": "HCPCS" } ], "description": "Revitalon 1 square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 549.86, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 549.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 549.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4161", "type": "HCPCS" } ], "description": "Bio-connekt per square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7891.71, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7891.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7891.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4162", "type": "HCPCS" } ], "description": "Amnio bio and woundex flow", "standard_charges": [ { "billing_class": "facility", "maximum": 6955.68, "minimum": 6955.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6955.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6955.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4164", "type": "HCPCS" } ], "description": "Helicoll, per square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 4092.32, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4092.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4092.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4165", "type": "HCPCS" } ], "description": "Keramatrix, per square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 120.89, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 120.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 120.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4167", "type": "HCPCS" } ], "description": "Truskin, per sq centimeter", "standard_charges": [ { "billing_class": "facility", "maximum": 327.96, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 327.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 327.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4169", "type": "HCPCS" } ], "description": "Artacent wound, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9308.47, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9308.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9308.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4170", "type": "HCPCS" } ], "description": "Cygnus, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2084.34, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2084.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2084.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4173", "type": "HCPCS" } ], "description": "Palingen or palingen xplus", "standard_charges": [ { "billing_class": "facility", "maximum": 3088.15, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3088.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3088.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4174", "type": "HCPCS" } ], "description": "Palingen or promatrx", "standard_charges": [ { "billing_class": "facility", "maximum": 3906.47, "minimum": 3906.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3906.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3906.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4176", "type": "HCPCS" } ], "description": "Neopatch, per sq centimeter", "standard_charges": [ { "billing_class": "facility", "maximum": 481.3, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 481.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 481.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4177", "type": "HCPCS" } ], "description": "Floweramnioflo, 0.1 cc", "standard_charges": [ { "billing_class": "facility", "maximum": 487.8, "minimum": 487.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 487.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 487.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4180", "type": "HCPCS" } ], "description": "Revita, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 4520.82, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4520.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4520.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4181", "type": "HCPCS" } ], "description": "Amnio wound, per square cm", "standard_charges": [ { "billing_class": "facility", "maximum": 441.84, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 441.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 441.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4183", "type": "HCPCS" } ], "description": "Surgigraft, 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 436.09, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 436.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 436.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4193", "type": "HCPCS" } ], "description": "Coll-e-derm 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6344.14, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6344.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6344.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4204", "type": "HCPCS" } ], "description": "Xwrap 1 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9271.91, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9271.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9271.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4205", "type": "HCPCS" } ], "description": "Membrane graft or wrap sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3142.54, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1971.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3142.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3142.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4213", "type": "HCPCS" } ], "description": "Ascent, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 186.94, "minimum": 186.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 186.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 186.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4217", "type": "HCPCS" } ], "description": "Woundfix biowound plus xplus", "standard_charges": [ { "billing_class": "facility", "maximum": 1005.03, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 630.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1005.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1005.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4219", "type": "HCPCS" } ], "description": "Surgigraft dual per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2138.16, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2138.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2138.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4221", "type": "HCPCS" } ], "description": "Amniowrap2 per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5205.21, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5205.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5205.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4222", "type": "HCPCS" } ], "description": "Progenamatrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 316.96, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 198.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 316.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 316.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4225", "type": "HCPCS" } ], "description": "Amniobind, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3955.38, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2481.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3955.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3955.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4227", "type": "HCPCS" } ], "description": "Amniocore per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3407.61, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3407.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3407.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4229", "type": "HCPCS" } ], "description": "Cogenex amnio memb per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1411.99, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 885.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1411.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1411.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4231", "type": "HCPCS" } ], "description": "Corplex p, per cc", "standard_charges": [ { "billing_class": "facility", "maximum": 2745.53, "minimum": 1722.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1722.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2745.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2745.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4232", "type": "HCPCS" } ], "description": "Corplex, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 718.53, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 450.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 718.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 718.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4234", "type": "HCPCS" } ], "description": "Xcellerate, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 691.43, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 433.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 691.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 691.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4235", "type": "HCPCS" } ], "description": "Amniorepair or altiply sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 257.86, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 161.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 257.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 257.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4236", "type": "HCPCS" } ], "description": "Carepatch per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1662.86, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1043.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1662.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1662.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4237", "type": "HCPCS" } ], "description": "cryo-cord, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1353.43, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1353.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1353.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4238", "type": "HCPCS" } ], "description": "Derm-maxx, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 4222.15, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2648.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4222.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4222.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4239", "type": "HCPCS" } ], "description": "Amnio-maxx or lite per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6844.67, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6844.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6844.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4246", "type": "HCPCS" } ], "description": "Coretext or protext, per cc", "standard_charges": [ { "billing_class": "facility", "maximum": 8726.2, "minimum": 8726.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8726.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8726.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4247", "type": "HCPCS" } ], "description": "Amniotext patch, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6170.97, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6170.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6170.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4248", "type": "HCPCS" } ], "description": "Dermacyte Amn mem allo sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7309.85, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7309.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7309.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26518", "type": "HCPCS" } ], "description": "Fusion of knuckle joints", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26520", "type": "HCPCS" } ], "description": "Release knuckle contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26525", "type": "HCPCS" } ], "description": "Release finger contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26530", "type": "HCPCS" } ], "description": "Revise knuckle joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26531", "type": "HCPCS" } ], "description": "Revise knuckle with implant", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26535", "type": "HCPCS" } ], "description": "Revise finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26536", "type": "HCPCS" } ], "description": "Revise/implant finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26540", "type": "HCPCS" } ], "description": "Repair hand joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26541", "type": "HCPCS" } ], "description": "Repair hand joint with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26542", "type": "HCPCS" } ], "description": "Repair hand joint with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26545", "type": "HCPCS" } ], "description": "Reconstruct finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26546", "type": "HCPCS" } ], "description": "Repair nonunion hand", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26548", "type": "HCPCS" } ], "description": "Reconstruct finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26550", "type": "HCPCS" } ], "description": "Construct thumb replacement", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26551", "type": "HCPCS" } ], "description": "Great toe-hand transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26553", "type": "HCPCS" } ], "description": "Single transfer toe-hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26554", "type": "HCPCS" } ], "description": "Double transfer toe-hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26555", "type": "HCPCS" } ], "description": "Positional change of finger", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26556", "type": "HCPCS" } ], "description": "Toe joint transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26560", "type": "HCPCS" } ], "description": "Repair of web finger", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26561", "type": "HCPCS" } ], "description": "Repair of web finger", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26562", "type": "HCPCS" } ], "description": "Repair of web finger", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26565", "type": "HCPCS" } ], "description": "Correct metacarpal flaw", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26567", "type": "HCPCS" } ], "description": "Correct finger deformity", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26568", "type": "HCPCS" } ], "description": "Lengthen metacarpal/finger", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26580", "type": "HCPCS" } ], "description": "Repair hand deformity", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26587", "type": "HCPCS" } ], "description": "Reconstruct extra finger", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26590", "type": "HCPCS" } ], "description": "Repair finger deformity", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26591", "type": "HCPCS" } ], "description": "Repair muscles of hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26593", "type": "HCPCS" } ], "description": "Release muscles of hand", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26596", "type": "HCPCS" } ], "description": "Excision constricting tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26600", "type": "HCPCS" } ], "description": "Treat metacarpal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4249", "type": "HCPCS" } ], "description": "Amniply, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7322.85, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7322.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7322.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4250", "type": "HCPCS" } ], "description": "AmnioAMP-MP per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7738.08, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7738.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7738.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4251", "type": "HCPCS" } ], "description": "Vim, per square centimeter", "standard_charges": [ { "billing_class": "facility", "maximum": 487.8, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 487.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 487.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4252", "type": "HCPCS" } ], "description": "Vendaje, per square centimet", "standard_charges": [ { "billing_class": "facility", "maximum": 208.59, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 130.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 208.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 208.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4253", "type": "HCPCS" } ], "description": "Zenith amniotic membrane psc", "standard_charges": [ { "billing_class": "facility", "maximum": 323.66, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 203.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 323.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 323.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4256", "type": "HCPCS" } ], "description": "Mlg complet, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2636.37, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1653.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2636.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2636.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4257", "type": "HCPCS" } ], "description": "Relese, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1321.72, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 829.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1321.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1321.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4258", "type": "HCPCS" } ], "description": "Enverse, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 198.97, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 124.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 198.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 198.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4259", "type": "HCPCS" } ], "description": "Celera per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3470.81, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2177.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3470.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3470.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4261", "type": "HCPCS" } ], "description": "Tag, per square centimeter", "standard_charges": [ { "billing_class": "facility", "maximum": 1962.64, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1962.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1962.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4262", "type": "HCPCS" } ], "description": "Dual layer impax, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 819.83, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 514.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 819.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 819.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4263", "type": "HCPCS" } ], "description": "Surgraft tl, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2481.47, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2481.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2481.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4264", "type": "HCPCS" } ], "description": "Cocoon membrane, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 8780.02, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8780.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8780.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4265", "type": "HCPCS" } ], "description": "Neostim tl per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5730.84, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3594.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5730.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5730.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4266", "type": "HCPCS" } ], "description": "Neostim per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2408.97, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1511.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2408.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2408.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4267", "type": "HCPCS" } ], "description": "Neostim dl per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1006.25, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 631.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1006.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1006.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4268", "type": "HCPCS" } ], "description": "Surgraft ft per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3561.54, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3561.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3561.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4269", "type": "HCPCS" } ], "description": "Surgraft xt per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2441.87, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2441.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2441.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4271", "type": "HCPCS" } ], "description": "Complete ft per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 4177.76, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 2620.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4177.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4177.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4272", "type": "HCPCS" } ], "description": "Esano a, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 948.77, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 948.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 948.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4274", "type": "HCPCS" } ], "description": "Esano ac, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5776.28, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5776.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5776.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4275", "type": "HCPCS" } ], "description": "Esano aca, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6971.8, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6971.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6971.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4276", "type": "HCPCS" } ], "description": "Orion, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1311.07, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 822.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1311.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1311.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4278", "type": "HCPCS" } ], "description": "Epieffect, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 829.45, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 520.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 829.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 829.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4279", "type": "HCPCS" } ], "description": "Vendaje ac, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6463.35, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 4054.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6463.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6463.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4280", "type": "HCPCS" } ], "description": "Xcell amnio matrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5583.68, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3502.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5583.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5583.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4281", "type": "HCPCS" } ], "description": "Barrera slor dl per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2406.78, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1509.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2406.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2406.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4282", "type": "HCPCS" } ], "description": "Cygnus dual per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1319.17, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 827.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1319.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1319.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4283", "type": "HCPCS" } ], "description": "Biovance tri or 3l, sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1789.63, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1122.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1789.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1789.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4285", "type": "HCPCS" } ], "description": "Nudyn dl or dl mesh pr sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 521.0, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 521.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 521.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26605", "type": "HCPCS" } ], "description": "Treat metacarpal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26607", "type": "HCPCS" } ], "description": "Treat metacarpal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26608", "type": "HCPCS" } ], "description": "Treat metacarpal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26615", "type": "HCPCS" } ], "description": "Treat metacarpal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26641", "type": "HCPCS" } ], "description": "Treat thumb dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26645", "type": "HCPCS" } ], "description": "Treat thumb fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26650", "type": "HCPCS" } ], "description": "Treat thumb fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26665", "type": "HCPCS" } ], "description": "Treat thumb fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26670", "type": "HCPCS" } ], "description": "Treat hand dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26675", "type": "HCPCS" } ], "description": "Treat hand dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26676", "type": "HCPCS" } ], "description": "Pin hand dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26685", "type": "HCPCS" } ], "description": "Treat hand dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26686", "type": "HCPCS" } ], "description": "Treat hand dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26700", "type": "HCPCS" } ], "description": "Treat knuckle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26705", "type": "HCPCS" } ], "description": "Treat knuckle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26706", "type": "HCPCS" } ], "description": "Pin knuckle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26715", "type": "HCPCS" } ], "description": "Treat knuckle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26720", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26725", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26727", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26735", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26740", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26742", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26746", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26750", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26755", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26756", "type": "HCPCS" } ], "description": "Pin finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26765", "type": "HCPCS" } ], "description": "Treat finger fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26770", "type": "HCPCS" } ], "description": "Treat finger dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26775", "type": "HCPCS" } ], "description": "Treat finger dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26776", "type": "HCPCS" } ], "description": "Pin finger dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26785", "type": "HCPCS" } ], "description": "Treat finger dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4286", "type": "HCPCS" } ], "description": "Nudyn sl or slw, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 686.71, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 686.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 686.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4289", "type": "HCPCS" } ], "description": "Revoshield+ amnio, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5039.25, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3161.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5039.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5039.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4290", "type": "HCPCS" } ], "description": "Membrane wrap hydr per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6014.63, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6014.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6014.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4291", "type": "HCPCS" } ], "description": "Lamellas xt, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9449.66, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9449.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9449.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4292", "type": "HCPCS" } ], "description": "Lamellas, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3985.76, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3985.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3985.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4293", "type": "HCPCS" } ], "description": "Acesso dl, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 4048.2, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4048.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4048.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4294", "type": "HCPCS" } ], "description": "Amnio quad-core, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 8131.79, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8131.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8131.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4295", "type": "HCPCS" } ], "description": "Amnio tri-core, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7155.97, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7155.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7155.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4296", "type": "HCPCS" } ], "description": "Rebound matrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7323.29, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7323.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7323.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4297", "type": "HCPCS" } ], "description": "Emerge matrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 4845.91, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3039.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4845.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4845.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4298", "type": "HCPCS" } ], "description": "Amnicore pro, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5887.23, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3693.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5887.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5887.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4300", "type": "HCPCS" } ], "description": "Acesso tl, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5730.84, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3594.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5730.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5730.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4301", "type": "HCPCS" } ], "description": "Activate matrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5243.66, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3289.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5243.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5243.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4302", "type": "HCPCS" } ], "description": "Complete aca, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5443.58, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3414.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5443.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5443.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4303", "type": "HCPCS" } ], "description": "Complete aa, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9248.66, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 5801.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9248.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9248.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4304", "type": "HCPCS" } ], "description": "Grafix plus, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2493.17, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 1563.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2493.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2493.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4309", "type": "HCPCS" } ], "description": "Via matrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5693.85, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5693.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5693.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4310", "type": "HCPCS" } ], "description": "Procenta, per 100 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 5840.0, "minimum": 3663.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_dollar": 3663.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5840.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5840.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4313", "type": "HCPCS" } ], "description": "Dermabind fm, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9393.92, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9393.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9393.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4319", "type": "HCPCS" } ], "description": "Sanograft, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2035.59, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2035.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2035.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4320", "type": "HCPCS" } ], "description": "Pellograft, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2440.06, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2440.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2440.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4322", "type": "HCPCS" } ], "description": "Caregraft, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6397.5, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6397.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6397.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4323", "type": "HCPCS" } ], "description": "Alloply, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5312.79, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5312.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5312.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4324", "type": "HCPCS" } ], "description": "Amniotx, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5256.37, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5256.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5256.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4325", "type": "HCPCS" } ], "description": "Acapatch, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7671.09, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7671.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7671.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4326", "type": "HCPCS" } ], "description": "Woundplus, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5090.55, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5090.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5090.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4328", "type": "HCPCS" } ], "description": "Most, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9469.07, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9469.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9469.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4331", "type": "HCPCS" } ], "description": "Axolotl graft, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5504.69, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5504.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5504.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4332", "type": "HCPCS" } ], "description": "Axolotl dualgraft, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 5506.58, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5506.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5506.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4333", "type": "HCPCS" } ], "description": "Ardeograft, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 2320.9, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2320.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2320.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26820", "type": "HCPCS" } ], "description": "Thumb fusion with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26841", "type": "HCPCS" } ], "description": "Fusion of thumb", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26842", "type": "HCPCS" } ], "description": "Thumb fusion with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26843", "type": "HCPCS" } ], "description": "Fusion of hand joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26844", "type": "HCPCS" } ], "description": "Fusion/graft of hand joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26850", "type": "HCPCS" } ], "description": "Fusion of knuckle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26852", "type": "HCPCS" } ], "description": "Fusion of knuckle with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26860", "type": "HCPCS" } ], "description": "Fusion of finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26862", "type": "HCPCS" } ], "description": "Fusion/graft of finger joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26910", "type": "HCPCS" } ], "description": "Amputate metacarpal bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26951", "type": "HCPCS" } ], "description": "Amputation of finger/thumb", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26952", "type": "HCPCS" } ], "description": "Amputation of finger/thumb", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26989", "type": "HCPCS" } ], "description": "Hand/finger surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26990", "type": "HCPCS" } ], "description": "Drainage of pelvis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26991", "type": "HCPCS" } ], "description": "Drainage of pelvis bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "26992", "type": "HCPCS" } ], "description": "Drainage of bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27000", "type": "HCPCS" } ], "description": "Incision of hip tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27001", "type": "HCPCS" } ], "description": "Incision of hip tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27003", "type": "HCPCS" } ], "description": "Incision of hip tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27005", "type": "HCPCS" } ], "description": "Incision of hip tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27006", "type": "HCPCS" } ], "description": "Incision of hip tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27025", "type": "HCPCS" } ], "description": "Incision of hip/thigh fascia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27027", "type": "HCPCS" } ], "description": "Buttock fasciotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27030", "type": "HCPCS" } ], "description": "Drainage of hip joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27033", "type": "HCPCS" } ], "description": "Exploration of hip joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27035", "type": "HCPCS" } ], "description": "Denervation of hip joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27036", "type": "HCPCS" } ], "description": "Excision of hip joint/muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27040", "type": "HCPCS" } ], "description": "Biopsy of soft tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27041", "type": "HCPCS" } ], "description": "Biopsy of soft tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27043", "type": "HCPCS" } ], "description": "Exc hip pelvis les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27045", "type": "HCPCS" } ], "description": "Exc hip/pelv tum deep 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27047", "type": "HCPCS" } ], "description": "Exc hip/pelvis les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4339", "type": "HCPCS" } ], "description": "Artacent vericlen, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7706.97, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7706.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7706.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4341", "type": "HCPCS" } ], "description": "Simplimax, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9567.9, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9567.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9567.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4342", "type": "HCPCS" } ], "description": "Theramend, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 11486.69, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11486.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11486.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4343", "type": "HCPCS" } ], "description": "Dermacyte ac matrx per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 7550.9, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7550.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7550.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4344", "type": "HCPCS" } ], "description": "Tri membrane wrap, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 8290.43, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8290.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8290.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4346", "type": "HCPCS" } ], "description": "Shelter dm matrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 11391.78, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11391.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11391.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4348", "type": "HCPCS" } ], "description": "Sentry sl matrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6346.85, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6346.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6346.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4349", "type": "HCPCS" } ], "description": "Mantle dl matrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 11391.78, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11391.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11391.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4350", "type": "HCPCS" } ], "description": "Palisade dm matrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 11391.78, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11391.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11391.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4351", "type": "HCPCS" } ], "description": "Enclose tl matrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 12205.49, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12205.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12205.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4352", "type": "HCPCS" } ], "description": "Overlay sl matrix, per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 6346.85, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6346.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6346.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q4353", "type": "HCPCS" } ], "description": "Xceed tl matrix per sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9616.27, "minimum": 119.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9616.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9616.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5137", "type": "HCPCS" } ], "description": "Inj, wezlana, sub cu, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 598.02, "minimum": 598.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 598.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 598.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5138", "type": "HCPCS" } ], "description": "Inj, wezlana, iv, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 921.73, "minimum": 11.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 921.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 921.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5140", "type": "HCPCS" } ], "description": "Inj adalimumab-fkjp, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 236.15, "minimum": 236.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 236.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 236.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5141", "type": "HCPCS" } ], "description": "Inj adalimumab-aaty, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 118.07, "minimum": 118.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 118.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 118.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5143", "type": "HCPCS" } ], "description": "Inj adalimumab-adbm, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 28.27, "minimum": 28.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q5145", "type": "HCPCS" } ], "description": "Inj, abrilada, 1 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 347.07, "minimum": 347.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 347.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 347.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9968", "type": "HCPCS" } ], "description": "Visualization adjunct", "standard_charges": [ { "billing_class": "facility", "maximum": 24.12, "minimum": 8.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q9969", "type": "HCPCS" } ], "description": "Non-HEU TC-99M add-on/dose", "standard_charges": [ { "billing_class": "facility", "maximum": 27.1, "minimum": 27.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27048", "type": "HCPCS" } ], "description": "Exc hip/pelv tum deep < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27049", "type": "HCPCS" } ], "description": "Resect hip/pelv tum < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27050", "type": "HCPCS" } ], "description": "Biopsy of sacroiliac joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27052", "type": "HCPCS" } ], "description": "Biopsy of hip joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27054", "type": "HCPCS" } ], "description": "Removal of hip joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27057", "type": "HCPCS" } ], "description": "Buttock fasciotomy w/dbrdmt", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27059", "type": "HCPCS" } ], "description": "Resect hip/pelv tum 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27060", "type": "HCPCS" } ], "description": "Removal of ischial bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27062", "type": "HCPCS" } ], "description": "Remove femur lesion/bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27065", "type": "HCPCS" } ], "description": "Remove hip bone les super", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27066", "type": "HCPCS" } ], "description": "Remove hip bone les deep", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27067", "type": "HCPCS" } ], "description": "Remove/graft hip bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27070", "type": "HCPCS" } ], "description": "Part remove hip bone super", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27071", "type": "HCPCS" } ], "description": "Part removal hip bone deep", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27075", "type": "HCPCS" } ], "description": "Resect hip tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27076", "type": "HCPCS" } ], "description": "Resect hip tum incl acetabul", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27077", "type": "HCPCS" } ], "description": "Resect hip tum w/innom bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27078", "type": "HCPCS" } ], "description": "Rsect hip tum incl femur", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27080", "type": "HCPCS" } ], "description": "Removal of tail bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27086", "type": "HCPCS" } ], "description": "Remove hip foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27087", "type": "HCPCS" } ], "description": "Remove hip foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27090", "type": "HCPCS" } ], "description": "Removal of hip prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27091", "type": "HCPCS" } ], "description": "Removal of hip prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27096", "type": "HCPCS" } ], "description": "Inject sacroiliac joint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27097", "type": "HCPCS" } ], "description": "Revision of hip tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27098", "type": "HCPCS" } ], "description": "Transfer tendon to pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27100", "type": "HCPCS" } ], "description": "Transfer of abdominal muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27105", "type": "HCPCS" } ], "description": "Transfer of spinal muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27110", "type": "HCPCS" } ], "description": "Transfer of iliopsoas muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27111", "type": "HCPCS" } ], "description": "Transfer of iliopsoas muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27120", "type": "HCPCS" } ], "description": "Reconstruction of hip socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27122", "type": "HCPCS" } ], "description": "Reconstruction of hip socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27125", "type": "HCPCS" } ], "description": "Partial hip replacement", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27130", "type": "HCPCS" } ], "description": "Total hip arthroplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27132", "type": "HCPCS" } ], "description": "Total hip arthroplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27134", "type": "HCPCS" } ], "description": "Revise hip joint replacement", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27137", "type": "HCPCS" } ], "description": "Revise hip joint replacement", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27138", "type": "HCPCS" } ], "description": "Revise hip joint replacement", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27140", "type": "HCPCS" } ], "description": "Transplant femur ridge", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27146", "type": "HCPCS" } ], "description": "Incision of hip bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27147", "type": "HCPCS" } ], "description": "Revision of hip bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27151", "type": "HCPCS" } ], "description": "Incision of hip bones", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27156", "type": "HCPCS" } ], "description": "Revision of hip bones", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27158", "type": "HCPCS" } ], "description": "Revision of pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27161", "type": "HCPCS" } ], "description": "Incision of neck of femur", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27165", "type": "HCPCS" } ], "description": "Incision/fixation of femur", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27170", "type": "HCPCS" } ], "description": "Repair/graft femur head/neck", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27175", "type": "HCPCS" } ], "description": "Treat slipped epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27176", "type": "HCPCS" } ], "description": "Treat slipped epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27177", "type": "HCPCS" } ], "description": "Treat slipped epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27178", "type": "HCPCS" } ], "description": "Treat slipped epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27179", "type": "HCPCS" } ], "description": "Revise head/neck of femur", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27181", "type": "HCPCS" } ], "description": "Treat slipped epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27185", "type": "HCPCS" } ], "description": "Revision of femur epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27187", "type": "HCPCS" } ], "description": "Reinforce hip bones", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27197", "type": "HCPCS" } ], "description": "Clsd tx pelvic ring fx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27198", "type": "HCPCS" } ], "description": "Clsd tx pelvic ring fx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27200", "type": "HCPCS" } ], "description": "Treat tail bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27202", "type": "HCPCS" } ], "description": "Treat tail bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27215", "type": "HCPCS" } ], "description": "Treat pelvic fracture(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27216", "type": "HCPCS" } ], "description": "Treat pelvic ring fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27217", "type": "HCPCS" } ], "description": "Treat pelvic ring fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27218", "type": "HCPCS" } ], "description": "Treat pelvic ring fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27220", "type": "HCPCS" } ], "description": "Treat hip socket fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27222", "type": "HCPCS" } ], "description": "Treat hip socket fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27226", "type": "HCPCS" } ], "description": "Treat hip wall fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27227", "type": "HCPCS" } ], "description": "Treat hip fracture(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27228", "type": "HCPCS" } ], "description": "Treat hip fracture(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27230", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27232", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27235", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27236", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27238", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27240", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27244", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27245", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27246", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27248", "type": "HCPCS" } ], "description": "Treat thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27250", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27252", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27253", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27254", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27256", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27257", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27258", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27259", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27265", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27266", "type": "HCPCS" } ], "description": "Treat hip dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27267", "type": "HCPCS" } ], "description": "Cltx thigh fx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27268", "type": "HCPCS" } ], "description": "Cltx thigh fx w/mnpj", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27269", "type": "HCPCS" } ], "description": "Optx thigh fx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27275", "type": "HCPCS" } ], "description": "Manipulation of hip joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27279", "type": "HCPCS" } ], "description": "Arthrodesis sacroiliac joint", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27280", "type": "HCPCS" } ], "description": "Fusion of sacroiliac joint", "standard_charges": [ { "billing_class": "facility", "maximum": 16906.49, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27282", "type": "HCPCS" } ], "description": "Fusion of pubic bones", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27284", "type": "HCPCS" } ], "description": "Fusion of hip joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27286", "type": "HCPCS" } ], "description": "Fusion of hip joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27290", "type": "HCPCS" } ], "description": "Amputation of leg at hip", "standard_charges": [ { "billing_class": "facility", "maximum": 16906.49, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27295", "type": "HCPCS" } ], "description": "Amputation of leg at hip", "standard_charges": [ { "billing_class": "facility", "maximum": 16906.49, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27299", "type": "HCPCS" } ], "description": "Pelvis/hip joint surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27301", "type": "HCPCS" } ], "description": "Drain thigh/knee lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27303", "type": "HCPCS" } ], "description": "Drainage of bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27305", "type": "HCPCS" } ], "description": "Incise thigh tendon & fascia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27306", "type": "HCPCS" } ], "description": "Incision of thigh tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27307", "type": "HCPCS" } ], "description": "Incision of thigh tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27310", "type": "HCPCS" } ], "description": "Exploration of knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27323", "type": "HCPCS" } ], "description": "Biopsy thigh soft tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27324", "type": "HCPCS" } ], "description": "Biopsy thigh soft tissues", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27325", "type": "HCPCS" } ], "description": "Neurectomy hamstring", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27326", "type": "HCPCS" } ], "description": "Neurectomy popliteal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27327", "type": "HCPCS" } ], "description": "Exc thigh/knee les sc < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27328", "type": "HCPCS" } ], "description": "Exc thigh/knee tum deep <5cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27329", "type": "HCPCS" } ], "description": "Resect thigh/knee tum < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27330", "type": "HCPCS" } ], "description": "Biopsy knee joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27331", "type": "HCPCS" } ], "description": "Explore/treat knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27332", "type": "HCPCS" } ], "description": "Removal of knee cartilage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27333", "type": "HCPCS" } ], "description": "Removal of knee cartilage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27334", "type": "HCPCS" } ], "description": "Remove knee joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27335", "type": "HCPCS" } ], "description": "Remove knee joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27337", "type": "HCPCS" } ], "description": "Exc thigh/knee les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27339", "type": "HCPCS" } ], "description": "Exc thigh/knee tum dep 5cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27340", "type": "HCPCS" } ], "description": "Removal of kneecap bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27345", "type": "HCPCS" } ], "description": "Removal of knee cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27347", "type": "HCPCS" } ], "description": "Remove knee cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27350", "type": "HCPCS" } ], "description": "Removal of kneecap", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27355", "type": "HCPCS" } ], "description": "Remove femur lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27356", "type": "HCPCS" } ], "description": "Remove femur lesion/graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27357", "type": "HCPCS" } ], "description": "Remove femur lesion/graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27360", "type": "HCPCS" } ], "description": "Partial removal leg bone(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27364", "type": "HCPCS" } ], "description": "Resect thigh/knee tum 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27365", "type": "HCPCS" } ], "description": "Resect femur/knee tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27372", "type": "HCPCS" } ], "description": "Removal of foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27380", "type": "HCPCS" } ], "description": "Repair of kneecap tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27381", "type": "HCPCS" } ], "description": "Repair/graft kneecap tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27385", "type": "HCPCS" } ], "description": "Repair of thigh muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { 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tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27391", "type": "HCPCS" } ], "description": "Incision of thigh tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27392", "type": "HCPCS" } ], "description": "Incision of thigh tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27393", "type": "HCPCS" } ], "description": "Lengthening of thigh tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27394", "type": "HCPCS" } ], "description": "Lengthening of thigh tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27395", "type": "HCPCS" } ], "description": "Lengthening of thigh tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27396", "type": "HCPCS" } ], "description": "Transplant of thigh tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27397", "type": "HCPCS" } ], "description": "Transplants of thigh tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27400", "type": "HCPCS" } ], "description": "Revise thigh muscles/tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27403", "type": "HCPCS" } ], "description": "Repair of knee cartilage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27405", "type": "HCPCS" } ], "description": "Repair of knee ligament", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27407", "type": "HCPCS" } ], "description": "Repair of knee ligament", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27409", "type": "HCPCS" } ], "description": "Repair of knee ligaments", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27412", "type": "HCPCS" } ], "description": "Autochondrocyte implant knee", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27415", "type": "HCPCS" } ], "description": "Osteochondral knee allograft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27416", "type": "HCPCS" } ], "description": "Osteochondral knee autograft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27418", "type": "HCPCS" } ], "description": "Repair degenerated kneecap", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27420", "type": "HCPCS" } ], "description": "Revision of unstable kneecap", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27422", "type": "HCPCS" } ], "description": "Revision of unstable kneecap", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27424", "type": "HCPCS" } ], "description": "Revision/removal of kneecap", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27425", "type": "HCPCS" } ], "description": "Lat retinacular release open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27427", "type": "HCPCS" } ], "description": "Reconstruction knee", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27428", "type": "HCPCS" } ], "description": "Reconstruction knee", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27429", "type": "HCPCS" } ], "description": "Reconstruction knee", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27430", "type": "HCPCS" } ], "description": "Revision of thigh muscles", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27435", "type": "HCPCS" } ], "description": "Incision of knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27437", "type": "HCPCS" } ], "description": "Revise kneecap", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27438", "type": "HCPCS" } ], "description": "Revise kneecap with implant", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27440", "type": "HCPCS" } ], "description": "Revision of knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27441", "type": "HCPCS" } ], "description": "Revision of knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27442", "type": "HCPCS" } ], "description": "Revision of knee joint", "standard_charges": [ { "billing_class": "facility", 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"Total knee arthroplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27448", "type": "HCPCS" } ], "description": "Incision of thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27450", "type": "HCPCS" } ], "description": "Incision of thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27454", "type": "HCPCS" } ], "description": "Realignment of thigh bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27455", "type": "HCPCS" } ], "description": "Realignment of knee", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27457", "type": "HCPCS" } ], "description": "Realignment of knee", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27465", "type": "HCPCS" } ], "description": "Shortening of thigh bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27466", "type": "HCPCS" } ], "description": "Lengthening of thigh bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27468", "type": "HCPCS" } ], "description": "Shorten/lengthen thighs", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27470", "type": "HCPCS" } ], "description": "Repair of thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { 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"outpatient" } ] }, { "code_information": [ { "code": "27479", "type": "HCPCS" } ], "description": "Surgery to stop leg growth", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27485", "type": "HCPCS" } ], "description": "Surgery to stop leg growth", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27486", "type": "HCPCS" } ], "description": "Revise/replace knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27487", "type": "HCPCS" } ], "description": "Revise/replace knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27488", "type": "HCPCS" } ], "description": "Removal of knee prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27495", "type": "HCPCS" } ], "description": "Reinforce thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27496", "type": "HCPCS" } ], "description": "Decompression of thigh/knee", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27497", "type": "HCPCS" } ], "description": "Decompression of thigh/knee", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27498", "type": "HCPCS" } ], "description": "Decompression of thigh/knee", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27499", "type": "HCPCS" } ], "description": "Decompression of thigh/knee", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27500", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27501", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27502", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27503", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27506", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27507", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27508", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27509", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27510", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27511", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27513", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27514", "type": "HCPCS" } ], "description": "Treatment of thigh fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27516", "type": "HCPCS" } ], "description": "Treat thigh fx growth plate", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27517", "type": "HCPCS" } ], "description": "Treat thigh fx growth plate", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27519", "type": "HCPCS" } ], "description": "Treat thigh fx growth plate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27520", "type": "HCPCS" } ], "description": "Treat kneecap fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27524", "type": "HCPCS" } ], "description": "Treat kneecap fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27530", "type": "HCPCS" } ], "description": "Treat knee fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27532", "type": "HCPCS" } ], "description": "Treat knee fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27535", "type": "HCPCS" } ], "description": "Treat knee fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27536", "type": "HCPCS" } ], "description": "Treat knee fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27538", "type": "HCPCS" } ], "description": "Treat knee fracture(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27540", "type": "HCPCS" } ], "description": "Treat knee fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27550", "type": "HCPCS" } ], "description": "Treat knee dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27552", "type": "HCPCS" } ], "description": "Treat knee dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27556", "type": "HCPCS" } ], "description": "Treat knee dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27557", "type": "HCPCS" } ], "description": "Treat knee dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27558", "type": "HCPCS" } ], "description": "Treat knee dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27560", "type": "HCPCS" } ], "description": "Treat kneecap dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27562", "type": "HCPCS" } ], "description": "Treat kneecap dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27566", "type": "HCPCS" } ], "description": "Treat kneecap dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27570", "type": "HCPCS" } ], "description": "Fixation of knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27580", "type": "HCPCS" } ], "description": "Fusion of knee", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27590", "type": "HCPCS" } ], "description": "Amputate leg at thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27591", "type": "HCPCS" } ], "description": "Amputate leg at thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27592", "type": "HCPCS" } ], "description": "Amputate leg at thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27594", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27596", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27598", "type": "HCPCS" } ], "description": "Amputate lower leg at knee", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27599", "type": "HCPCS" } ], "description": "Leg surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27600", "type": "HCPCS" } ], "description": "Decompression of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27601", "type": "HCPCS" } ], "description": "Decompression of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27602", "type": "HCPCS" } ], "description": "Decompression of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27603", "type": "HCPCS" } ], "description": "Drain lower leg lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27604", "type": "HCPCS" } ], "description": "Drain lower leg bursa", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27605", "type": "HCPCS" } ], "description": "Incision of achilles tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27606", "type": "HCPCS" } ], "description": "Incision of achilles tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27607", "type": "HCPCS" } ], "description": "Treat lower leg bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27610", "type": "HCPCS" } ], "description": "Explore/treat ankle joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27612", "type": "HCPCS" } ], "description": "Exploration of ankle joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27613", "type": "HCPCS" } ], "description": "Biopsy lower leg soft tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27614", "type": "HCPCS" } ], "description": "Biopsy lower leg soft tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27615", "type": "HCPCS" } ], "description": "Resect leg/ankle tum < 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27616", "type": "HCPCS" } ], "description": "Resect leg/ankle tum 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27618", "type": "HCPCS" } ], "description": "Exc leg/ankle tum < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27619", "type": "HCPCS" } ], "description": "Exc leg/ankle tum deep <5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27620", "type": "HCPCS" } ], "description": "Explore/treat ankle joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27625", "type": "HCPCS" } ], "description": "Remove ankle joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27626", "type": "HCPCS" } ], "description": "Remove ankle joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27630", "type": "HCPCS" } ], "description": "Removal of tendon lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27632", "type": "HCPCS" } ], "description": "Exc leg/ankle les sc 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27634", "type": "HCPCS" } ], "description": "Exc leg/ankle tum dep 5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27635", "type": "HCPCS" } ], "description": "Remove lower leg bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27637", "type": "HCPCS" } ], "description": "Remove/graft leg bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27638", "type": "HCPCS" } ], "description": "Remove/graft leg bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27640", "type": "HCPCS" } ], "description": "Partial removal of tibia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27641", "type": "HCPCS" } ], "description": "Partial removal of fibula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27645", "type": "HCPCS" } ], "description": "Resect tibia tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27646", "type": "HCPCS" } ], "description": "Resect fibula tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27647", "type": "HCPCS" } ], "description": "Resect talus/calcaneus tum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27650", "type": "HCPCS" } ], "description": "Repair achilles tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27652", "type": "HCPCS" } ], "description": "Repair/graft achilles tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27654", "type": "HCPCS" } ], "description": "Repair of achilles tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27656", "type": "HCPCS" } ], "description": "Repair leg fascia defect", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27658", "type": "HCPCS" } ], "description": "Repair of leg tendon each", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27659", "type": "HCPCS" } ], "description": "Repair of leg tendon each", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27664", "type": "HCPCS" } ], "description": "Repair of leg tendon each", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27665", "type": "HCPCS" } ], "description": "Repair of leg tendon each", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27675", "type": "HCPCS" } ], "description": "Repair lower leg tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27676", "type": "HCPCS" } ], "description": "Repair lower leg tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27680", "type": "HCPCS" } ], "description": "Release of lower leg tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27681", "type": "HCPCS" } ], "description": "Release of lower leg tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27685", "type": "HCPCS" } ], "description": "Revision of lower leg tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27686", "type": "HCPCS" } ], "description": "Revise lower leg tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27687", "type": "HCPCS" } ], "description": "Revision of calf tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27690", "type": "HCPCS" } ], "description": "Revise lower leg tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue 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"standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27696", "type": "HCPCS" } ], "description": "Repair of ankle ligaments", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27698", "type": "HCPCS" } ], "description": "Repair of ankle ligament", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { 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"standard_charges": [ { "billing_class": "facility", "maximum": 26163.21, "minimum": 15689.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26163.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27703", "type": "HCPCS" } ], "description": "Reconstruction ankle joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 16906.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16906.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27704", "type": "HCPCS" } ], "description": "Removal of ankle implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27705", "type": "HCPCS" } ], "description": "Incision of tibia", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27707", "type": "HCPCS" } ], "description": "Incision of fibula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27709", "type": "HCPCS" } ], "description": "Incision of tibia & fibula", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27712", "type": "HCPCS" } ], "description": "Realignment of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27715", "type": "HCPCS" } ], "description": "Revision of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27720", "type": "HCPCS" } ], "description": "Repair of tibia", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27722", "type": "HCPCS" } ], "description": "Repair/graft of tibia", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27724", "type": "HCPCS" } ], "description": "Repair/graft of tibia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27725", "type": "HCPCS" } ], "description": "Repair of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27726", "type": "HCPCS" } ], "description": "Repair fibula nonunion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27727", "type": "HCPCS" } ], "description": "Repair of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27730", "type": "HCPCS" } ], "description": "Repair of tibia epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27732", "type": "HCPCS" } ], "description": "Repair of fibula epiphysis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27734", "type": "HCPCS" } ], "description": "Repair lower leg epiphyses", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27740", "type": "HCPCS" } ], "description": "Repair of leg epiphyses", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27742", "type": "HCPCS" } ], "description": "Repair of leg epiphyses", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27745", "type": "HCPCS" } ], "description": "Reinforce tibia", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27750", "type": "HCPCS" } ], "description": "Treatment of tibia fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27752", "type": "HCPCS" } ], "description": "Treatment of tibia fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27756", "type": "HCPCS" } ], "description": "Treatment of tibia fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27758", "type": "HCPCS" } ], "description": "Treatment of tibia fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27759", "type": "HCPCS" } ], "description": "Treatment of tibia fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27760", "type": "HCPCS" } ], "description": "Cltx medial ankle fx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27762", "type": "HCPCS" } ], "description": "Cltx med ankle fx w/mnpj", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27766", "type": "HCPCS" } ], "description": "Optx medial ankle fx", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27767", "type": "HCPCS" } ], "description": "Cltx post ankle fx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27768", "type": "HCPCS" } ], "description": "Cltx post ankle fx w/mnpj", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27769", "type": "HCPCS" } ], "description": "Optx post ankle fx", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27780", "type": "HCPCS" } ], "description": "Treatment of fibula fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27781", "type": "HCPCS" } ], "description": "Treatment of fibula fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27784", "type": "HCPCS" } ], "description": "Treatment of fibula fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27786", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27788", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27792", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27808", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27810", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27814", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27816", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27818", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27822", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27823", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27824", "type": "HCPCS" } ], "description": "Treat lower leg fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27825", "type": "HCPCS" } ], "description": "Treat lower leg fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27826", "type": "HCPCS" } ], "description": "Treat lower leg fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27827", "type": "HCPCS" } ], "description": "Treat lower leg fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27828", "type": "HCPCS" } ], "description": "Treat lower leg fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27829", "type": "HCPCS" } ], "description": "Treat lower leg joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27830", "type": "HCPCS" } ], "description": "Treat lower leg dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27831", "type": "HCPCS" } ], "description": "Treat lower leg dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27832", "type": "HCPCS" } ], "description": "Treat lower leg dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27840", "type": "HCPCS" } ], "description": "Treat ankle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27842", "type": "HCPCS" } ], "description": "Treat ankle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27846", "type": "HCPCS" } ], "description": "Treat ankle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27848", "type": "HCPCS" } ], "description": "Treat ankle dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27860", "type": "HCPCS" } ], "description": "Fixation of ankle joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27870", "type": "HCPCS" } ], "description": "Fusion of ankle joint open", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27871", "type": "HCPCS" } ], "description": "Fusion of tibiofibular joint", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27880", "type": "HCPCS" } ], "description": "Amputation of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27881", "type": "HCPCS" } ], "description": "Amputation of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27882", "type": "HCPCS" } ], "description": "Amputation of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27884", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27886", "type": "HCPCS" } ], "description": "Amputation follow-up surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27888", "type": "HCPCS" } ], "description": "Amputation of foot at ankle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27889", "type": "HCPCS" } ], "description": "Amputation of foot at ankle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27892", "type": "HCPCS" } ], "description": "Decompression of leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27893", "type": "HCPCS" } ], "description": "Decompression of leg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27894", "type": "HCPCS" } ], "description": "Decompression of leg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27899", "type": "HCPCS" } ], "description": "Leg/ankle surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28001", "type": "HCPCS" } ], "description": "Drainage of bursa of foot", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28002", "type": "HCPCS" } ], "description": "Treatment of foot infection", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28003", "type": "HCPCS" } ], "description": "Treatment of foot infection", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28005", "type": "HCPCS" } ], "description": "Treat foot bone lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28008", "type": "HCPCS" } ], "description": "Incision of foot fascia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28010", "type": "HCPCS" } ], "description": "Incision of toe tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28011", "type": "HCPCS" } ], "description": "Incision of toe tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28020", "type": "HCPCS" } ], "description": "Exploration of foot joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28022", "type": "HCPCS" } ], "description": "Exploration of foot joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28024", "type": "HCPCS" } ], "description": "Exploration of toe joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28035", "type": "HCPCS" } ], "description": "Decompression of tibia nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28039", "type": "HCPCS" } ], "description": "Exc foot/toe tum sc 1.5 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28041", "type": "HCPCS" } ], "description": "Exc foot/toe tum dep 1.5cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28043", "type": "HCPCS" } ], "description": "Exc foot/toe tum sc < 1.5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28045", "type": "HCPCS" } ], "description": "Exc foot/toe tum deep <1.5cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28046", "type": "HCPCS" } ], "description": "Resect foot/toe tumor < 3 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28047", "type": "HCPCS" } ], "description": "Resect foot/toe tumor 3 cm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28050", "type": "HCPCS" } ], "description": "Biopsy of foot joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28052", "type": "HCPCS" } ], "description": "Biopsy of foot joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28054", "type": "HCPCS" } ], "description": "Biopsy of toe joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28055", "type": "HCPCS" } ], "description": "Neurectomy foot", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28060", "type": "HCPCS" } ], "description": "Partial removal foot fascia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28062", "type": "HCPCS" } ], "description": "Removal of foot fascia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28070", "type": "HCPCS" } ], "description": "Removal of foot joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28072", "type": "HCPCS" } ], "description": "Removal of foot joint lining", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28080", "type": "HCPCS" } ], "description": "Removal of foot lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28086", "type": "HCPCS" } ], "description": "Excise foot tendon sheath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28088", "type": "HCPCS" } ], "description": "Excise foot tendon sheath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28090", "type": "HCPCS" } ], "description": "Removal of foot lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28092", "type": "HCPCS" } ], "description": "Removal of toe lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28100", "type": "HCPCS" } ], "description": "Removal of ankle/heel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28102", "type": "HCPCS" } ], "description": "Remove/graft foot lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28103", "type": "HCPCS" } ], "description": "Remove/graft foot lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28104", "type": "HCPCS" } ], "description": "Removal of foot lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28106", "type": "HCPCS" } ], "description": "Remove/graft foot lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28107", "type": "HCPCS" } ], "description": "Remove/graft foot lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28108", "type": "HCPCS" } ], "description": "Removal of toe lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28110", "type": "HCPCS" } ], "description": "Part removal of metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": 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"facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28113", "type": "HCPCS" } ], "description": "Part removal of metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28114", "type": "HCPCS" } ], "description": "Removal of metatarsal heads", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28116", "type": "HCPCS" } ], "description": "Revision of foot", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28118", "type": "HCPCS" } ], "description": "Removal of heel bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28119", "type": "HCPCS" } ], "description": "Removal of heel spur", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28120", "type": "HCPCS" } ], "description": "Part removal of ankle/heel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28122", "type": "HCPCS" } ], "description": "Partial removal of foot bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { 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"outpatient" } ] }, { "code_information": [ { "code": "28140", "type": "HCPCS" } ], "description": "Removal of metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28150", "type": "HCPCS" } ], "description": "Removal of toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28153", "type": "HCPCS" } ], "description": "Partial removal of toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28160", "type": "HCPCS" } ], "description": "Partial removal of toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28171", "type": "HCPCS" } ], "description": "Resect tarsal tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28173", "type": "HCPCS" } ], "description": "Resect metatarsal tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28175", "type": "HCPCS" } ], "description": "Resect phalanx of toe tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28190", "type": "HCPCS" } ], "description": "Removal of foot foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28192", "type": "HCPCS" } ], "description": "Removal of foot foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28193", "type": "HCPCS" } ], "description": "Removal of foot foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28200", "type": "HCPCS" } ], "description": "Repair of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28202", "type": "HCPCS" } ], "description": "Repair/graft of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28208", "type": "HCPCS" } ], "description": "Repair of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28210", "type": "HCPCS" } ], "description": "Repair/graft of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28220", "type": "HCPCS" } ], "description": "Release of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28222", "type": "HCPCS" } ], "description": "Release of foot tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28225", "type": "HCPCS" } ], "description": "Release of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28226", "type": "HCPCS" } ], "description": "Release of foot tendons", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28230", "type": "HCPCS" } ], "description": "Incision of foot tendon(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28232", "type": "HCPCS" } ], "description": "Incision of toe tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28234", "type": "HCPCS" } ], "description": "Incision of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28238", "type": "HCPCS" } ], "description": "Revision of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28240", "type": "HCPCS" } ], "description": "Release of big toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28250", "type": "HCPCS" } ], "description": "Revision of foot fascia", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28260", "type": "HCPCS" } ], "description": "Release of midfoot joint", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28261", "type": "HCPCS" } ], "description": "Revision of foot tendon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28262", "type": "HCPCS" } ], "description": "Revision of foot and ankle", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28264", "type": "HCPCS" } ], "description": "Release of midfoot joint", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28270", "type": "HCPCS" } ], "description": "Release of foot contracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28272", "type": "HCPCS" } ], "description": "Release of toe joint each", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28280", "type": "HCPCS" } ], "description": "Fusion of toes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28285", "type": "HCPCS" } ], "description": "Repair of hammertoe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28286", "type": "HCPCS" } ], "description": "Repair of hammertoe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28288", "type": "HCPCS" } ], "description": "Partial removal of foot bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28289", "type": "HCPCS" } ], "description": "Corrj halux rigdus w/o implt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28291", "type": "HCPCS" } ], "description": "Corrj halux rigdus w/implt", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28292", "type": "HCPCS" } ], "description": "Correction hallux valgus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28295", "type": "HCPCS" } ], "description": "Correction hallux valgus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28296", "type": "HCPCS" } ], "description": "Correction hallux valgus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28297", "type": "HCPCS" } ], "description": "Correction hallux valgus", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28298", "type": "HCPCS" } ], "description": "Correction hallux valgus", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28299", "type": "HCPCS" } ], "description": "Correction hallux valgus", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28300", "type": "HCPCS" } ], "description": "Incision of heel bone", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28302", "type": "HCPCS" } ], "description": "Incision of ankle bone", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28304", "type": "HCPCS" } ], "description": "Incision of midfoot bones", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28305", "type": "HCPCS" } ], "description": "Incise/graft midfoot bones", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28306", "type": "HCPCS" } ], "description": "Incision of metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28307", "type": "HCPCS" } ], "description": "Incision of metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28308", "type": "HCPCS" } ], "description": "Incision of metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28309", "type": "HCPCS" } ], "description": "Incision of metatarsals", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28310", "type": "HCPCS" } ], "description": "Revision of big toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28312", "type": "HCPCS" } ], "description": "Revision of toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28313", "type": "HCPCS" } ], "description": "Repair deformity of toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28315", "type": "HCPCS" } ], "description": "Removal of sesamoid bone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28320", "type": "HCPCS" } ], "description": "Repair of foot bones", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28322", "type": "HCPCS" } ], "description": "Repair of metatarsals", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28340", "type": "HCPCS" } ], "description": "Resect enlarged toe tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28341", "type": "HCPCS" } ], "description": "Resect enlarged toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28344", "type": "HCPCS" } ], "description": "Repair extra toe(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28345", "type": "HCPCS" } ], "description": "Repair webbed toe(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28360", "type": "HCPCS" } ], "description": "Reconstruct cleft foot", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28400", "type": "HCPCS" } ], "description": "Treatment of heel fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28405", "type": "HCPCS" } ], "description": "Treatment of heel fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28406", "type": "HCPCS" } ], "description": "Treatment of heel fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28415", "type": "HCPCS" } ], "description": "Treat heel fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28420", "type": "HCPCS" } ], "description": "Treat/graft heel fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28430", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28435", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28436", "type": "HCPCS" } ], "description": "Treatment of ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28445", "type": "HCPCS" } ], "description": "Treat ankle fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28446", "type": "HCPCS" } ], "description": "Osteochondral talus autogrft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28450", "type": "HCPCS" } ], "description": "Treat midfoot fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28455", "type": "HCPCS" } ], "description": "Treat midfoot fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28456", "type": "HCPCS" } ], "description": "Treat midfoot fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28465", "type": "HCPCS" } ], "description": "Treat midfoot fracture each", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28470", "type": "HCPCS" } ], "description": "Treat metatarsal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28475", "type": "HCPCS" } ], "description": "Treat metatarsal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28476", "type": "HCPCS" } ], "description": "Treat metatarsal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28485", "type": "HCPCS" } ], "description": "Treat metatarsal fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28490", "type": "HCPCS" } ], "description": "Treat big toe fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28495", "type": "HCPCS" } ], "description": "Treat big toe fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28496", "type": "HCPCS" } ], "description": "Treat big toe fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28505", "type": "HCPCS" } ], "description": "Treat big toe fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28510", "type": "HCPCS" } ], "description": "Treatment of toe fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28515", "type": "HCPCS" } ], "description": "Treatment of toe fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28525", "type": "HCPCS" } ], "description": "Treat toe fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28530", "type": "HCPCS" } ], "description": "Treat sesamoid bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28531", "type": "HCPCS" } ], "description": "Treat sesamoid bone fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28540", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28545", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28546", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28555", "type": "HCPCS" } ], "description": "Repair foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28570", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28575", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28576", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28585", "type": "HCPCS" } ], "description": "Repair foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28600", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28605", "type": "HCPCS" } ], "description": "Treat foot dislocation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", 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schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28740", "type": "HCPCS" } ], "description": "Fusion of foot bones", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28750", "type": "HCPCS" } ], "description": "Fusion of big toe joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28755", "type": "HCPCS" } ], "description": "Fusion of big toe joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28760", "type": "HCPCS" } ], "description": "Fusion of big toe joint", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28800", "type": "HCPCS" } ], "description": "Amputation of midfoot", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28805", "type": "HCPCS" } ], "description": "Amputation thru metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28810", "type": "HCPCS" } ], "description": "Amputation toe & metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28820", "type": "HCPCS" } ], "description": "Amputation of toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28825", "type": "HCPCS" } ], "description": "Partial amputation of toe", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28890", "type": "HCPCS" } ], "description": "Hi enrgy eswt plantar fascia", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "28899", "type": "HCPCS" } ], "description": "Foot/toes surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29000", "type": "HCPCS" } ], "description": "Application of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29010", "type": "HCPCS" } ], "description": "Application of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29015", "type": "HCPCS" } ], "description": "Application of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29035", "type": "HCPCS" } ], "description": "Application of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29040", "type": "HCPCS" } ], "description": "Application of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29044", "type": "HCPCS" } ], "description": "Application of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29046", "type": "HCPCS" } ], "description": "Application of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29049", "type": "HCPCS" } ], "description": "Application of figure eight", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29055", "type": "HCPCS" } ], "description": "Application of shoulder cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29058", "type": "HCPCS" } ], "description": "Application of shoulder cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29065", "type": "HCPCS" } ], "description": "Application of long arm cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29075", "type": "HCPCS" } ], "description": "Application of forearm cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29085", "type": "HCPCS" } ], "description": "Apply hand/wrist cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29086", "type": "HCPCS" } ], "description": "Apply finger cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29105", "type": "HCPCS" } ], "description": "Apply long arm splint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29125", "type": "HCPCS" } ], "description": "Apply forearm splint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29126", "type": "HCPCS" } ], "description": "Apply forearm splint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29130", "type": "HCPCS" } ], "description": "Application of finger splint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29131", "type": "HCPCS" } ], "description": "Application of finger splint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29200", "type": "HCPCS" } ], "description": "Strapping of chest", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29240", "type": "HCPCS" } ], "description": "Strapping of shoulder", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29260", "type": "HCPCS" } ], "description": "Strapping of elbow or wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29280", "type": "HCPCS" } ], "description": "Strapping of hand or finger", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29305", "type": "HCPCS" } ], "description": "Application of hip cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29325", "type": "HCPCS" } ], "description": "Application of hip casts", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29345", "type": "HCPCS" } ], "description": "Application of long leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29355", "type": "HCPCS" } ], "description": "Application of long leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29358", "type": "HCPCS" } ], "description": "Apply long leg cast brace", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29365", "type": "HCPCS" } ], "description": "Application of long leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29405", "type": "HCPCS" } ], "description": "Apply short leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29425", "type": "HCPCS" } ], "description": "Apply short leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29435", "type": "HCPCS" } ], "description": "Apply short leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29440", "type": "HCPCS" } ], "description": "Addition of walker to cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29445", "type": "HCPCS" } ], "description": "Apply rigid leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29450", "type": "HCPCS" } ], "description": "Application of leg cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29505", "type": "HCPCS" } ], "description": "Application long leg splint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29515", "type": "HCPCS" } ], "description": "Application lower leg splint", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29520", "type": "HCPCS" } ], "description": "Strapping of hip", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29530", "type": "HCPCS" } ], "description": "Strapping of knee", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29540", "type": "HCPCS" } ], "description": "Strapping of ankle and/or ft", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29550", "type": "HCPCS" } ], "description": "Strapping of toes", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29580", "type": "HCPCS" } ], "description": "Application of paste boot", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29581", "type": "HCPCS" } ], "description": "Apply multlay comprs lwr leg", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29584", "type": "HCPCS" } ], "description": "Appl multlay comprs arm/hand", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29700", "type": "HCPCS" } ], "description": "Removal/revision of cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29705", "type": "HCPCS" } ], "description": "Removal/revision of cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29710", "type": "HCPCS" } ], "description": "Removal/revision of cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29720", "type": "HCPCS" } ], "description": "Repair of body cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29730", "type": "HCPCS" } ], "description": "Windowing of cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29740", "type": "HCPCS" } ], "description": "Wedging of cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29750", "type": "HCPCS" } ], "description": "Wedging of clubfoot cast", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 269.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29799", "type": "HCPCS" } ], "description": "Casting/strapping procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 156.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29800", "type": "HCPCS" } ], "description": "Jaw arthroscopy/surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29804", "type": "HCPCS" } ], "description": "Jaw arthroscopy/surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29805", "type": "HCPCS" } ], "description": "Shoulder arthroscopy dx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29806", "type": "HCPCS" } ], "description": "Shoulder arthroscopy/surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32220", "type": "HCPCS" } ], "description": "Release of lung", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32225", "type": "HCPCS" } ], "description": "Partial release of lung", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32310", "type": "HCPCS" } ], "description": "Removal of chest lining", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32320", "type": "HCPCS" } ], "description": "Free/remove chest lining", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32400", "type": "HCPCS" } ], "description": "Needle biopsy chest lining", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32408", "type": "HCPCS" } ], "description": "Core ndl bx lng/med perq", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32440", "type": "HCPCS" } ], "description": "Remove lung pneumonectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32442", "type": "HCPCS" } ], "description": "Sleeve pneumonectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32445", "type": "HCPCS" } ], "description": "Removal of lung extrapleural", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32480", "type": "HCPCS" } ], "description": "Partial removal of lung", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32482", "type": "HCPCS" } ], "description": "Bilobectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32484", "type": "HCPCS" } ], "description": "Segmentectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32486", "type": "HCPCS" } ], "description": "Sleeve lobectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32488", "type": "HCPCS" } ], "description": "Completion pneumonectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32491", "type": "HCPCS" } ], "description": "Lung volume reduction", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32501", "type": "HCPCS" } ], "description": "Repair bronchus add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32503", "type": "HCPCS" } ], "description": "Resect apical lung tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32504", "type": "HCPCS" } ], "description": "Resect apical lung tum/chest", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32505", "type": "HCPCS" } ], "description": "Wedge resect of lung initial", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32506", "type": "HCPCS" } ], "description": "Wedge resect of lung add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32507", "type": "HCPCS" } ], "description": "Wedge resect of lung diag", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32540", "type": "HCPCS" } ], "description": "Removal of lung lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32550", "type": "HCPCS" } ], "description": "Insert pleural cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32551", "type": "HCPCS" } ], "description": "Insertion of chest tube", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32552", "type": "HCPCS" } ], "description": "Remove lung catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32553", "type": "HCPCS" } ], "description": "Ins mark thor for rt perq", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1334.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1334.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32554", "type": "HCPCS" } ], "description": "Aspirate pleura w/o imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32555", "type": "HCPCS" } ], "description": "Aspirate pleura w/ imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32556", "type": "HCPCS" } ], "description": "Insert cath pleura w/o image", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32557", "type": "HCPCS" } ], "description": "Insert cath pleura w/ image", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32560", "type": "HCPCS" } ], "description": "Treat pleurodesis w/agent", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32561", "type": "HCPCS" } ], "description": "Lyse chest fibrin init day", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32562", "type": "HCPCS" } ], "description": "Lyse chest fibrin subq day", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32215", "type": "HCPCS" } ], "description": "Treat chest lining", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32200", "type": "HCPCS" } ], "description": "Drain open lung lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32160", "type": "HCPCS" } ], "description": "Open chest heart massage", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32151", "type": "HCPCS" } ], "description": "Remove lung foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32150", "type": "HCPCS" } ], "description": "Removal of lung lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32141", "type": "HCPCS" } ], "description": "Remove/treat lung lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32140", "type": "HCPCS" } ], "description": "Removal of lung lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32124", "type": "HCPCS" } ], "description": "Explore chest free adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32120", "type": "HCPCS" } ], "description": "Re-exploration of chest", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32110", "type": "HCPCS" } ], "description": "Explore/repair chest", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32100", "type": "HCPCS" } ], "description": "Exploration of chest", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32098", "type": "HCPCS" } ], "description": "Open biopsy of lung pleura", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32097", "type": "HCPCS" } ], "description": "Open wedge/bx lung nodule", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32096", "type": "HCPCS" } ], "description": "Open wedge/bx lung infiltr", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32036", "type": "HCPCS" } ], "description": "Thoracostomy w/flap drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32035", "type": "HCPCS" } ], "description": "Thoracostomy w/rib resection", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31899", "type": "HCPCS" } ], "description": "Airways surgical procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 192.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31830", "type": "HCPCS" } ], "description": "Revise windpipe scar", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31825", "type": "HCPCS" } ], "description": "Repair of windpipe defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31820", "type": "HCPCS" } ], "description": "Closure of windpipe lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31805", "type": "HCPCS" } ], "description": "Repair of windpipe injury", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0175", "type": "HCPCS" } ], "description": "Flutamide, oral, 125 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 97.4, "minimum": 97.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 97.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 97.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "S0177", "type": "HCPCS" } ], "description": "Levamisole HCl, oral, 50 mg", "standard_charges": [ { "billing_class": "facility", "maximum": 9.65, "minimum": 9.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31800", "type": "HCPCS" } ], "description": "Repair of windpipe injury", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31786", "type": "HCPCS" } ], "description": "Remove windpipe lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31785", "type": "HCPCS" } ], "description": "Remove windpipe lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31781", "type": "HCPCS" } ], "description": "Reconstruct windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31780", "type": "HCPCS" } ], "description": "Reconstruct windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31775", "type": "HCPCS" } ], "description": "Reconstruct bronchus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31770", "type": "HCPCS" } ], "description": "Repair/graft of bronchus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31766", "type": "HCPCS" } ], "description": "Reconstruction of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31760", "type": "HCPCS" } ], "description": "Repair of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31755", "type": "HCPCS" } ], "description": "Repair of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31750", "type": "HCPCS" } ], "description": "Repair of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31730", "type": "HCPCS" } ], "description": "Intro windpipe wire/tube", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31725", "type": "HCPCS" } ], "description": "Clearance of airways", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31720", "type": "HCPCS" } ], "description": "Clearance of airways", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 211.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 211.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31717", "type": "HCPCS" } ], "description": "Bronchial brush biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31661", "type": "HCPCS" } ], "description": "Bronch thermoplsty 2/> lobes", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31660", "type": "HCPCS" } ], "description": "Bronch thermoplsty 1 lobe", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31653", "type": "HCPCS" } ], "description": "Bronch ebus samplng 3/> node", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31652", "type": "HCPCS" } ], "description": "Bronch ebus samplng 1/2 node", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31649", "type": "HCPCS" } ], "description": "Bronchial valve remov addl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31648", "type": "HCPCS" } ], "description": "Bronchial valve remov init", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31647", "type": "HCPCS" } ], "description": "Bronchial valve init insert", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31646", "type": "HCPCS" } ], "description": "Bronchoscopy reclear airway", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31645", "type": "HCPCS" } ], "description": "Bronchoscopy clear airways", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31643", "type": "HCPCS" } ], "description": "Diag bronchoscope/catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ 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"setting": "outpatient" } ] }, { "code_information": [ { "code": "31636", "type": "HCPCS" } ], "description": "Bronchoscopy bronch stents", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31635", "type": "HCPCS" } ], "description": "Bronchoscopy w/fb removal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31634", "type": "HCPCS" } ], "description": "Bronch w/balloon occlusion", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31631", "type": "HCPCS" } ], "description": "Bronchoscopy dilate w/stent", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", 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"Repair windpipe opening", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31612", "type": "HCPCS" } ], "description": "Puncture/clear windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31611", "type": "HCPCS" } ], "description": "Surgery/speech prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31610", "type": "HCPCS" } ], "description": "Incision of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31605", "type": "HCPCS" } ], "description": "Incision of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31603", "type": "HCPCS" } ], "description": "Incision of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31601", "type": "HCPCS" } ], "description": "Incision of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31600", "type": "HCPCS" } ], "description": "Incision of windpipe", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31599", "type": "HCPCS" } ], "description": "Larynx surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31592", "type": "HCPCS" } ], "description": "Cricotracheal resection", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31591", "type": "HCPCS" } ], "description": "Laryngoplasty medialization", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31590", "type": "HCPCS" } ], "description": "Reinnervate larynx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31587", "type": "HCPCS" } ], "description": "Laryngoplasty cricoid split", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31584", "type": "HCPCS" } ], "description": "Laryngoplasty fx rdctj fixj", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31580", "type": "HCPCS" } ], "description": "Laryngoplasty laryngeal web", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31579", "type": "HCPCS" } ], "description": "Laryngoscopy telescopic", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31578", "type": "HCPCS" } ], "description": "Largsc w/removal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31577", "type": "HCPCS" } ], "description": "Largsc w/rmvl foreign bdy(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31576", "type": "HCPCS" } ], "description": "Laryngoscopy with biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31575", "type": "HCPCS" } ], "description": "Diagnostic laryngoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 192.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31574", "type": "HCPCS" } ], "description": "Largsc w/njx augmentation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31573", "type": "HCPCS" } ], "description": "Largsc w/ther injection", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31572", "type": "HCPCS" } ], "description": "Largsc w/laser dstrj les", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31571", "type": "HCPCS" } ], "description": "Laryngoscop w/vc inj + scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31570", "type": "HCPCS" } ], "description": "Laryngoscope w/vc inj", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31561", "type": "HCPCS" } ], "description": "Larynscop remve cart + scop", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31560", "type": "HCPCS" } ], "description": "Laryngoscop w/arytenoidectom", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31554", "type": "HCPCS" } ], "description": "Laryngoplasty laryngeal sten", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31553", "type": "HCPCS" } ], "description": "Laryngoplasty laryngeal sten", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31552", "type": "HCPCS" } ], "description": "Laryngoplasty laryngeal sten", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31551", "type": "HCPCS" } ], "description": "Laryngoplasty laryngeal sten", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31546", "type": "HCPCS" } ], "description": "Remove vc lesion scope/graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31545", "type": "HCPCS" } ], "description": "Remove vc lesion w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31541", "type": "HCPCS" } ], "description": "Larynscop w/tumr exc + scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31540", "type": "HCPCS" } ], "description": "Laryngoscopy w/exc of tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31536", "type": "HCPCS" } ], "description": "Laryngoscopy w/bx & op scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31535", "type": "HCPCS" } ], "description": "Laryngoscopy w/biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31531", "type": "HCPCS" } ], "description": "Laryngoscopy w/fb & op scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31530", "type": "HCPCS" } ], "description": "Laryngoscopy w/fb removal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31529", "type": "HCPCS" } ], "description": "Laryngoscopy and dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31528", "type": "HCPCS" } ], "description": "Laryngoscopy and dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31527", "type": "HCPCS" } ], "description": "Laryngoscopy for treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31526", "type": "HCPCS" } ], "description": "Dx laryngoscopy w/oper scope", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31525", "type": "HCPCS" } ], "description": "Dx laryngoscopy excl nb", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31520", "type": "HCPCS" } ], "description": "Dx laryngoscopy newborn", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31515", "type": "HCPCS" } ], "description": "Laryngoscopy for aspiration", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31513", "type": "HCPCS" } ], "description": "Injection into vocal cord", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31512", "type": "HCPCS" } ], "description": "Removal of larynx lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31511", "type": "HCPCS" } ], "description": "Remove foreign body larynx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 192.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31510", "type": "HCPCS" } ], "description": "Laryngoscopy with biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31505", "type": "HCPCS" } ], "description": "Diagnostic laryngoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 192.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31502", "type": "HCPCS" } ], "description": "Change of windpipe airway", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31500", "type": "HCPCS" } ], "description": "Insert emergency airway", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31420", "type": "HCPCS" } ], "description": "Removal of epiglottis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31400", "type": "HCPCS" } ], "description": "Revision of larynx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31395", "type": "HCPCS" } ], "description": "Reconstruct larynx & pharynx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31390", "type": "HCPCS" } ], "description": "Removal of larynx & pharynx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31382", "type": "HCPCS" } ], "description": "Partial removal of larynx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access 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Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31296", "type": "HCPCS" } ], "description": "Sinus endo w/balloon dil", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31295", "type": "HCPCS" } ], "description": "Sinus endo w/balloon dil", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31294", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31293", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { 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surg", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31290", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31288", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31287", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31276", "type": "HCPCS" } ], "description": "Sinus endoscopy surgical", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31267", "type": "HCPCS" } ], "description": "Endoscopy maxillary sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31259", "type": "HCPCS" } ], "description": "Nsl/sins ndsc sphn tiss rmvl", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31257", "type": "HCPCS" } ], "description": "Nsl/sins ndsc tot w/sphendt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31256", "type": "HCPCS" } ], "description": "Exploration maxillary sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31255", "type": "HCPCS" } ], "description": "Removal of ethmoid sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31254", "type": "HCPCS" } ], "description": "Revision of ethmoid sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31253", "type": "HCPCS" } ], "description": "Nsl/sins ndsc total", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6804.96, "payers_information": [ { 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surg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31239", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3594.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3594.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31238", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31237", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy surg", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31235", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy dx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31233", "type": "HCPCS" } ], "description": "Nasal/sinus endoscopy dx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 377.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31231", "type": "HCPCS" } ], "description": "Nasal endoscopy dx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 192.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31230", "type": "HCPCS" } ], "description": "Removal of upper jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31225", "type": "HCPCS" } ], "description": "Removal of upper jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31205", "type": "HCPCS" } ], "description": "Removal of ethmoid sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31201", "type": "HCPCS" } ], "description": "Removal of ethmoid sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31200", "type": "HCPCS" } ], "description": "Removal of ethmoid sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": 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"facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31086", "type": "HCPCS" } ], "description": "Removal of frontal sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31085", "type": "HCPCS" } ], "description": "Removal of frontal sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31084", "type": "HCPCS" } ], "description": "Removal of frontal sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": 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Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31075", "type": "HCPCS" } ], "description": "Exploration of frontal sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31070", "type": "HCPCS" } ], "description": "Exploration of frontal sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, 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"Exploration sphenoid sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31040", "type": "HCPCS" } ], "description": "Exploration behind upper jaw", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31032", "type": "HCPCS" } ], "description": "Explore sinus remove polyps", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31030", "type": "HCPCS" } ], "description": "Exploration maxillary sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31020", "type": "HCPCS" } ], "description": "Exploration maxillary sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31002", "type": "HCPCS" } ], "description": "Irrigation sphenoid sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "31000", "type": "HCPCS" } ], "description": "Irrigation maxillary sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30999", "type": "HCPCS" } ], "description": "Nasal surgery procedure", 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"outpatient" } ] }, { "code_information": [ { "code": "30920", "type": "HCPCS" } ], "description": "Ligation upper jaw artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30915", "type": "HCPCS" } ], "description": "Ligation nasal sinus artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30906", "type": "HCPCS" } ], "description": "Repeat control of nosebleed", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30905", "type": "HCPCS" } ], "description": "Control of nosebleed", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30903", "type": "HCPCS" } ], "description": "Control of nosebleed", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30901", "type": "HCPCS" } ], "description": "Control of nosebleed", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30802", "type": "HCPCS" } ], "description": "Ablate inf turbinate submuc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30801", "type": "HCPCS" } ], "description": "Ablate inf turbinate superf", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30630", "type": "HCPCS" } ], "description": "Repair nasal septum defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30620", "type": "HCPCS" } ], "description": "Intranasal reconstruction", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30600", "type": "HCPCS" } ], "description": "Repair mouth/nose fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30580", "type": "HCPCS" } ], "description": "Repair upper jaw fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30560", "type": "HCPCS" } ], "description": "Release of nasal adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30545", "type": "HCPCS" } ], "description": "Repair nasal defect", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30540", "type": "HCPCS" } ], "description": "Repair nasal defect", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30520", "type": "HCPCS" } ], "description": "Repair of nasal septum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30469", "type": "HCPCS" } ], "description": "Rpr nsl vlv collapse w/rmdlg", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30468", "type": "HCPCS" } ], "description": "Rpr nsl vlv collapse w/implt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30465", "type": "HCPCS" } ], "description": "Repair Nasal Stenosis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30462", "type": "HCPCS" } ], "description": "Revision of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30460", "type": "HCPCS" } ], "description": "Revision of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30450", "type": "HCPCS" } ], "description": "Revision of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30435", "type": "HCPCS" } ], "description": "Revision of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30430", "type": "HCPCS" } ], "description": "Revision of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30420", "type": "HCPCS" } ], "description": "Reconstruction of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30410", "type": "HCPCS" } ], "description": "Reconstruction of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30400", "type": "HCPCS" } ], "description": "Reconstruction of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30320", "type": "HCPCS" } ], "description": "Remove nasal foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30310", "type": "HCPCS" } ], "description": "Remove nasal foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30300", "type": "HCPCS" } ], "description": "Remove nasal foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30220", "type": "HCPCS" } ], "description": "Insert nasal septal button", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30210", "type": "HCPCS" } ], "description": "Nasal sinus therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30200", "type": "HCPCS" } ], "description": "Injection treatment of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30160", "type": "HCPCS" } ], "description": "Removal of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30150", "type": "HCPCS" } ], "description": "Partial removal of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30140", "type": "HCPCS" } ], "description": "Resect inferior turbinate", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30130", "type": "HCPCS" } ], "description": "Excise inferior turbinate", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30125", "type": "HCPCS" } ], "description": "Removal of nose lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30124", "type": "HCPCS" } ], "description": "Removal of nose lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30120", "type": "HCPCS" } ], "description": "Revision of nose", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30118", "type": "HCPCS" } ], "description": "Removal of intranasal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30117", "type": "HCPCS" } ], "description": "Removal of intranasal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30115", "type": "HCPCS" } ], "description": "Removal of nose polyp(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30110", "type": "HCPCS" } ], "description": "Removal of nose polyp(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30100", "type": "HCPCS" } ], "description": "Intranasal biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30020", "type": "HCPCS" } ], "description": "Drainage of nose lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "30000", "type": "HCPCS" } ], "description": "Drainage of nose lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29999", "type": "HCPCS" } ], "description": "Arthroscopy of joint", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 237.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29916", "type": "HCPCS" } ], "description": "Hip arthro w/labral repair", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29915", "type": "HCPCS" } ], "description": "Hip arthro acetabuloplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29914", "type": "HCPCS" } ], "description": "Hip arthro w/femoroplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "29907", "type": "HCPCS" } ], "description": "Subtalar arthro w/fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": 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Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32653", "type": "HCPCS" } ], "description": "Thoracoscopy remov fb/fibrin", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32654", "type": "HCPCS" } ], "description": "Thoracoscopy contrl bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32655", "type": "HCPCS" } ], "description": "Thoracoscopy resect bullae", 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Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32659", "type": "HCPCS" } ], "description": "Thoracoscopy w/sac drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32661", "type": "HCPCS" } ], "description": "Thoracoscopy w/pericard exc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32662", "type": "HCPCS" } ], "description": "Thoracoscopy w/mediast exc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32663", "type": "HCPCS" } ], "description": "Thoracoscopy w/lobectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32664", "type": "HCPCS" } ], "description": "Thoracoscopy w/ th nrv exc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32665", "type": "HCPCS" } ], "description": "Thoracoscop w/esoph musc exc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32666", "type": "HCPCS" } ], "description": "Thoracoscopy w/wedge resect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32667", "type": "HCPCS" } ], "description": "Thoracoscopy w/w resect addl", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32668", "type": "HCPCS" } ], "description": "Thoracoscopy w/w resect diag", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32669", "type": "HCPCS" } ], "description": "Thoracoscopy remove segment", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32670", "type": "HCPCS" } ], "description": "Thoracoscopy bilobectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32671", "type": "HCPCS" } ], "description": "Thoracoscopy pneumonectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32672", "type": "HCPCS" } ], "description": "Thoracoscopy for lvrs", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32673", "type": "HCPCS" } ], "description": "Thoracoscopy w/thymus resect", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32674", "type": "HCPCS" } ], "description": "Thoracoscopy lymph node exc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32701", "type": "HCPCS" } ], "description": "Thorax stereo rad targetw/tx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32800", "type": "HCPCS" } ], "description": "Repair lung hernia", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32810", "type": "HCPCS" } ], "description": "Close chest after drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32815", "type": "HCPCS" } ], "description": "Close bronchial fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32820", "type": "HCPCS" } ], "description": "Reconstruct injured chest", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32850", "type": "HCPCS" } ], "description": "Donor pneumonectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32851", "type": "HCPCS" } ], "description": "Lung transplant single", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32852", "type": "HCPCS" } ], "description": "Lung transplant with bypass", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32853", "type": "HCPCS" } ], "description": "Lung transplant double", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32854", "type": "HCPCS" } ], "description": "Lung transplant with bypass", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32855", "type": "HCPCS" } ], "description": "Prepare donor lung single", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32856", "type": "HCPCS" } ], "description": "Prepare donor lung double", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32900", "type": "HCPCS" } ], "description": "Removal of rib(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32905", "type": "HCPCS" } ], "description": "Revise & repair chest wall", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32906", "type": "HCPCS" } ], "description": "Revise & repair chest wall", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32940", "type": "HCPCS" } ], "description": "Revision of lung", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32960", "type": "HCPCS" } ], "description": "Therapeutic pneumothorax", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32994", "type": "HCPCS" } ], "description": "Ablate pulm tumor perq crybl", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32997", "type": "HCPCS" } ], "description": "Total lung lavage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32998", "type": "HCPCS" } ], "description": "Perq rf ablate tx pul tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "32999", "type": "HCPCS" } ], "description": "Chest surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33016", "type": "HCPCS" } ], "description": "Pericardiocentesis w/imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33017", "type": "HCPCS" } ], "description": "Prcrd drg 6yr+ w/o cgen car", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33018", "type": "HCPCS" } ], "description": "Prcrd drg 0-5yr or w/anomly", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33019", "type": "HCPCS" } ], "description": "Perq prcrd drg insj cath ct", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33020", "type": "HCPCS" } ], "description": "Incision of heart sac", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33025", "type": "HCPCS" } ], "description": "Incision of heart sac", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33030", "type": "HCPCS" } ], "description": "Partial removal of heart sac", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33031", "type": "HCPCS" } ], "description": "Partial removal of heart sac", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33050", "type": "HCPCS" } ], "description": "Resect heart sac lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33120", "type": "HCPCS" } ], "description": "Removal of heart lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33130", "type": "HCPCS" } ], "description": "Removal of heart lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33140", "type": "HCPCS" } ], "description": "Heart revascularize (tmr)", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33141", "type": "HCPCS" } ], "description": "Heart Tmr W/Other Procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33202", "type": "HCPCS" } ], "description": "Insert epicard eltrd open", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33203", "type": "HCPCS" } ], "description": "Insert epicard eltrd endo", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33206", "type": "HCPCS" } ], "description": "Insert heart pm atrial", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33207", "type": "HCPCS" } ], "description": "Insert heart pm ventricular", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33208", "type": "HCPCS" } ], "description": "Insrt heart pm atrial & vent", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33210", "type": "HCPCS" } ], "description": "Insert electrd/pm cath sngl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33211", "type": "HCPCS" } ], "description": "Insert card electrodes dual", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33212", "type": "HCPCS" } ], "description": "Insert pulse gen sngl lead", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33213", "type": "HCPCS" } ], "description": "Insert pulse gen dual leads", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33214", "type": "HCPCS" } ], "description": "Upgrade of pacemaker system", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33215", "type": "HCPCS" } ], "description": "Reposition pacing-defib lead", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33216", "type": "HCPCS" } ], "description": "Insert 1 electrode pm-defib", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33217", "type": "HCPCS" } ], "description": "Insert 2 electrode pm-defib", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33218", "type": "HCPCS" } ], "description": "Repair lead pace-defib one", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33220", "type": "HCPCS" } ], "description": "Repair lead pace-defib dual", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33221", "type": "HCPCS" } ], "description": "Insert pulse gen mult leads", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33222", "type": "HCPCS" } ], "description": "Relocation pocket pacemaker", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33223", "type": "HCPCS" } ], "description": "Relocate pocket for defib", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33224", "type": "HCPCS" } ], "description": "Insert pacing lead & connect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33226", "type": "HCPCS" } ], "description": "Reposition l ventric lead", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33227", "type": "HCPCS" } ], "description": "Remove&replace pm gen singl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33228", "type": "HCPCS" } ], "description": "Remv&replc pm gen dual lead", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10078.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10078.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33229", "type": "HCPCS" } ], "description": "Remv&replc pm gen mult leads", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33230", "type": "HCPCS" } ], "description": "Insrt pulse gen w/dual leads", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33231", "type": "HCPCS" } ], "description": "Insrt pulse gen w/mult leads", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 30265.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30265.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33233", "type": "HCPCS" } ], "description": "Removal of pm generator", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33234", "type": "HCPCS" } ], "description": "Removal of pacemaker system", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33235", "type": "HCPCS" } ], "description": "Removal pacemaker electrode", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33236", "type": "HCPCS" } ], "description": "Remove electrode/thoracotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33237", "type": "HCPCS" } ], "description": "Remove electrode/thoracotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33238", "type": "HCPCS" } ], "description": "Remove electrode/thoracotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33240", "type": "HCPCS" } ], "description": "Insrt pulse gen w/singl lead", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33241", "type": "HCPCS" } ], "description": "Remove pulse generator", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33243", "type": "HCPCS" } ], "description": "Remove eltrd/thoracotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33244", "type": "HCPCS" } ], "description": "Remove elctrd transvenously", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33249", "type": "HCPCS" } ], "description": "Insj/rplcmt defib w/lead(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 30265.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30265.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33250", "type": "HCPCS" } ], "description": "Ablate heart dysrhythm focus", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33251", "type": "HCPCS" } ], "description": "Ablate heart dysrhythm focus", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33254", "type": "HCPCS" } ], "description": "Ablate atria lmtd", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33255", "type": "HCPCS" } ], "description": "Ablate atria w/o bypass ext", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33256", "type": "HCPCS" } ], "description": "Ablate atria w/bypass exten", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33257", "type": "HCPCS" } ], "description": "Ablate atria lmtd add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33258", "type": "HCPCS" } ], "description": "Ablate atria x10sv add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33259", "type": "HCPCS" } ], "description": "Ablate atria w/bypass add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33261", "type": "HCPCS" } ], "description": "Ablate heart dysrhythm focus", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33262", "type": "HCPCS" } ], "description": "Rmvl& replc pulse gen 1 lead", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33263", "type": "HCPCS" } ], "description": "Rmvl & rplcmt dfb gen 2 lead", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 21447.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21447.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33264", "type": "HCPCS" } ], "description": "Rmvl & rplcmt dfb gen mlt ld", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 30265.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30265.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33265", "type": "HCPCS" } ], "description": "Ablate atria lmtd endo", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33266", "type": "HCPCS" } ], "description": "Ablate atria x10sv endo", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33267", "type": "HCPCS" } ], "description": "Excl laa open any method", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33268", "type": "HCPCS" } ], "description": "Excl laa opn oth px any meth", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33269", "type": "HCPCS" } ], "description": "Excl laa thrscp any method", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33270", "type": "HCPCS" } ], "description": "Ins/rep subq defibrillator", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 30265.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30265.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33271", "type": "HCPCS" } ], "description": "Insj subq impltbl dfb elctrd", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33272", "type": "HCPCS" } ], "description": "Rmvl of subq defibrillator", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33273", "type": "HCPCS" } ], "description": "Repos prev impltbl subq dfb", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33274", "type": "HCPCS" } ], "description": "Tcat insj/rpl perm ldls pm", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18572.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18572.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33275", "type": "HCPCS" } ], "description": "Tcat rmvl perm ldls pm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33285", "type": "HCPCS" } ], "description": "Insj subq car rhythm mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7979.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33286", "type": "HCPCS" } ], "description": "Rmvl subq car rhythm mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33289", "type": "HCPCS" } ], "description": "Tcat impl wrls p-art prs snr", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 27657.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27657.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33300", "type": "HCPCS" } ], "description": "Repair of heart wound", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33305", "type": "HCPCS" } ], "description": "Repair of heart wound", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33310", "type": "HCPCS" } ], "description": "Exploratory heart surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33315", "type": "HCPCS" } ], "description": "Exploratory heart surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33320", "type": "HCPCS" } ], "description": "Repair major blood vessel(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33321", "type": "HCPCS" } ], "description": "Repair major vessel", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33322", "type": "HCPCS" } ], "description": "Repair major blood vessel(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33330", "type": "HCPCS" } ], "description": "Insert major vessel graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33335", "type": "HCPCS" } ], "description": "Insert major vessel graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33340", "type": "HCPCS" } ], "description": "Perq clsr tcat l atr apndge", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33361", "type": "HCPCS" } ], "description": "Replace aortic valve perq", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33362", "type": "HCPCS" } ], "description": "Replace aortic valve open", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33363", "type": "HCPCS" } ], "description": "Replace aortic valve open", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33364", "type": "HCPCS" } ], "description": "Replace aortic valve open", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33365", "type": "HCPCS" } ], "description": "Replace aortic valve open", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33366", "type": "HCPCS" } ], "description": "Trcath replace aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33367", "type": "HCPCS" } ], "description": "Replace aortic valve w/byp", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33368", "type": "HCPCS" } ], "description": "Replace aortic valve w/byp", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33369", "type": "HCPCS" } ], "description": "Replace aortic valve w/byp", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33390", "type": "HCPCS" } ], "description": "Valvuloplasty aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33391", "type": "HCPCS" } ], "description": "Valvuloplasty aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33404", "type": "HCPCS" } ], "description": "Prepare heart-aorta conduit", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33405", "type": "HCPCS" } ], "description": "Replacement aortic valve opn", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33406", "type": "HCPCS" } ], "description": "Replacement aortic valve opn", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33410", "type": "HCPCS" } ], "description": "Replacement aortic valve opn", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33411", "type": "HCPCS" } ], "description": "Replacement of aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33412", "type": "HCPCS" } ], "description": "Replacement of aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33413", "type": "HCPCS" } ], "description": "Replacement of aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33414", "type": "HCPCS" } ], "description": "Repair of aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33415", "type": "HCPCS" } ], "description": "Revision subvalvular tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33416", "type": "HCPCS" } ], "description": "Revise ventricle muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33417", "type": "HCPCS" } ], "description": "Repair of aortic valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33418", "type": "HCPCS" } ], "description": "Repair tcat mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33420", "type": "HCPCS" } ], "description": "Revision of mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33422", "type": "HCPCS" } ], "description": "Revision of mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33425", "type": "HCPCS" } ], "description": "Repair of mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33426", "type": "HCPCS" } ], "description": "Repair of mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33427", "type": "HCPCS" } ], "description": "Repair of mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33430", "type": "HCPCS" } ], "description": "Replacement of mitral valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33440", "type": "HCPCS" } ], "description": "Rplcmt a-valve tlcj autol pv", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33460", "type": "HCPCS" } ], "description": "Revision of tricuspid valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33463", "type": "HCPCS" } ], "description": "Valvuloplasty tricuspid", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33464", "type": "HCPCS" } ], "description": "Valvuloplasty tricuspid", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33465", "type": "HCPCS" } ], "description": "Replace tricuspid valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33468", "type": "HCPCS" } ], "description": "Revision of tricuspid valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33471", "type": "HCPCS" } ], "description": "Valvotomy pulmonary valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33474", "type": "HCPCS" } ], "description": "Revision of pulmonary valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33475", "type": "HCPCS" } ], "description": "Replacement pulmonary valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33476", "type": "HCPCS" } ], "description": "Revision of heart chamber", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33477", "type": "HCPCS" } ], "description": "Implant tcat pulm vlv perq", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33478", "type": "HCPCS" } ], "description": "Revision of heart chamber", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33496", "type": "HCPCS" } ], "description": "Repair prosth valve clot", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33500", "type": "HCPCS" } ], "description": "Repair heart vessel fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33501", "type": "HCPCS" } ], "description": "Repair heart vessel fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33502", "type": "HCPCS" } ], "description": "Coronary artery correction", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33503", "type": "HCPCS" } ], "description": "Coronary artery graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33504", "type": "HCPCS" } ], "description": "Coronary artery graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33505", "type": "HCPCS" } ], "description": "Repair artery w/tunnel", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33506", "type": "HCPCS" } ], "description": "Repair artery translocation", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33507", "type": "HCPCS" } ], "description": "Repair art intramural", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33509", "type": "HCPCS" } ], "description": "Ndsc hrv uxtr art 1 sgm cab", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33510", "type": "HCPCS" } ], "description": "Cabg vein single", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33511", "type": "HCPCS" } ], "description": "Cabg vein two", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33512", "type": "HCPCS" } ], "description": "Cabg vein three", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33513", "type": "HCPCS" } ], "description": "Cabg vein four", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33514", "type": "HCPCS" } ], "description": "Cabg vein five", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33516", "type": "HCPCS" } ], "description": "Cabg vein six or more", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33517", "type": "HCPCS" } ], "description": "Cabg artery-vein single", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33518", "type": "HCPCS" } ], "description": "Cabg artery-vein two", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33519", "type": "HCPCS" } ], "description": "Cabg artery-vein three", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33521", "type": "HCPCS" } ], "description": "Cabg artery-vein four", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33522", "type": "HCPCS" } ], "description": "Cabg artery-vein five", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33523", "type": "HCPCS" } ], "description": "Cabg art-vein six or more", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33530", "type": "HCPCS" } ], "description": "Coronary artery bypass/reop", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33533", "type": "HCPCS" } ], "description": "Cabg arterial single", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33534", "type": "HCPCS" } ], "description": "Cabg arterial two", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33535", "type": "HCPCS" } ], "description": "Cabg arterial three", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33536", "type": "HCPCS" } ], "description": "Cabg arterial four or more", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33542", "type": "HCPCS" } ], "description": "Removal of heart lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33545", "type": "HCPCS" } ], "description": "Repair of heart damage", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33548", "type": "HCPCS" } ], "description": "Restore/remodel ventricle", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33572", "type": "HCPCS" } ], "description": "Open coronary endarterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33600", "type": "HCPCS" } ], "description": "Closure of valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33602", "type": "HCPCS" } ], "description": "Closure of valve", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33606", "type": "HCPCS" } ], "description": "Anastomosis/artery-aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33608", "type": "HCPCS" } ], "description": "Repair anomaly w/conduit", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33610", "type": "HCPCS" } ], "description": "Repair by enlargement", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33611", "type": "HCPCS" } ], "description": "Repair double ventricle", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33612", "type": "HCPCS" } ], "description": "Repair double ventricle", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33615", "type": "HCPCS" } ], "description": "Repair modified fontan", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33617", "type": "HCPCS" } ], "description": "Repair single ventricle", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33619", "type": "HCPCS" } ], "description": "Repair single ventricle", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33620", "type": "HCPCS" } ], "description": "Apply r&l pulm art bands", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33621", "type": "HCPCS" } ], "description": "Transthor cath for stent", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33622", "type": "HCPCS" } ], "description": "Redo compl cardiac anomaly", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33641", "type": "HCPCS" } ], "description": "Repair heart septum defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33645", "type": "HCPCS" } ], "description": "Revision of heart veins", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33647", "type": "HCPCS" } ], "description": "Repair heart septum defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33660", "type": "HCPCS" } ], "description": "Repair of heart defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33665", "type": "HCPCS" } ], "description": "Repair of heart defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33670", "type": "HCPCS" } ], "description": "Repair of heart chambers", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33675", "type": "HCPCS" } ], "description": "Close Mult Vsd", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33676", "type": "HCPCS" } ], "description": "Close mult vsd w/resection", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33677", "type": "HCPCS" } ], "description": "Cl mult vsd w/rem pul band", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33681", "type": "HCPCS" } ], "description": "Repair heart septum defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33684", "type": "HCPCS" } ], "description": "Repair heart septum defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33688", "type": "HCPCS" } ], "description": "Repair heart septum defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33690", "type": "HCPCS" } ], "description": "Reinforce pulmonary artery", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33692", "type": "HCPCS" } ], "description": "Repair of heart defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33694", "type": "HCPCS" } ], "description": "Repair of heart defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33697", "type": "HCPCS" } ], "description": "Repair of heart defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33702", "type": "HCPCS" } ], "description": "Repair of heart defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33710", "type": "HCPCS" } ], "description": "Repair of heart defects", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33720", "type": "HCPCS" } ], "description": "Repair of heart defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33724", "type": "HCPCS" } ], "description": "Repair Venous Anomaly", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33726", "type": "HCPCS" } ], "description": "Repair Pul Venous Stenosis", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33730", "type": "HCPCS" } ], "description": "Repair heart-vein defect(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33732", "type": "HCPCS" } ], "description": "Repair heart-vein defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33735", "type": "HCPCS" } ], "description": "Revision of heart chamber", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33736", "type": "HCPCS" } ], "description": "Revision of heart chamber", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33737", "type": "HCPCS" } ], "description": "Revision of heart chamber", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33741", "type": "HCPCS" } ], "description": "Tas congenital car anomal", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33745", "type": "HCPCS" } ], "description": "Tis cgen car anomal 1st shnt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33746", "type": "HCPCS" } ], "description": "Tis cgen car anomal ea addl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33750", "type": "HCPCS" } ], "description": "Major vessel shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33755", "type": "HCPCS" } ], "description": "Major vessel shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33762", "type": "HCPCS" } ], "description": "Major vessel shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33764", "type": "HCPCS" } ], "description": "Major vessel shunt & graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33766", "type": "HCPCS" } ], "description": "Major vessel shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33767", "type": "HCPCS" } ], "description": "Major vessel shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33768", "type": "HCPCS" } ], "description": "Cavopulmonary shunting", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33770", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33771", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33774", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33775", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33776", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33777", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33778", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33779", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33780", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33781", "type": "HCPCS" } ], "description": "Repair great vessels defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33782", "type": "HCPCS" } ], "description": "Nikaidoh proc", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33783", "type": "HCPCS" } ], "description": "Nikaidoh proc w/ostia implt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33786", "type": "HCPCS" } ], "description": "Repair arterial trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33788", "type": "HCPCS" } ], "description": "Revision of pulmonary artery", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33800", "type": "HCPCS" } ], "description": "Aortic suspension", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33802", "type": "HCPCS" } ], "description": "Repair vessel defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33803", "type": "HCPCS" } ], "description": "Repair vessel defect", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33813", "type": "HCPCS" } ], "description": "Repair septal defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33814", "type": "HCPCS" } ], "description": "Repair septal defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33820", "type": "HCPCS" } ], "description": "Revise major vessel", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33822", "type": "HCPCS" } ], "description": "Revise major vessel", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33824", "type": "HCPCS" } ], "description": "Revise major vessel", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33840", "type": "HCPCS" } ], "description": "Remove aorta constriction", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33845", "type": "HCPCS" } ], "description": "Remove aorta constriction", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33851", "type": "HCPCS" } ], "description": "Remove aorta constriction", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33852", "type": "HCPCS" } ], "description": "Repair septal defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33853", "type": "HCPCS" } ], "description": "Repair septal defect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33858", "type": "HCPCS" } ], "description": "As-aort grf f/aortic dsj", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33859", "type": "HCPCS" } ], "description": "As-aort grf f/ds oth/thn dsj", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33863", "type": "HCPCS" } ], "description": "Ascending aortic graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33864", "type": "HCPCS" } ], "description": "Ascending aortic graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33871", "type": "HCPCS" } ], "description": "Transvrs a-arch grf hypthrm", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33875", "type": "HCPCS" } ], "description": "Thoracic aortic graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33877", "type": "HCPCS" } ], "description": "Thoracoabdominal graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33880", "type": "HCPCS" } ], "description": "Endovasc taa repr incl subcl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33881", "type": "HCPCS" } ], "description": "Endovasc taa repr w/o subcl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33883", "type": "HCPCS" } ], "description": "Insert endovasc prosth taa", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33884", "type": "HCPCS" } ], "description": "Endovasc prosth taa add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33886", "type": "HCPCS" } ], "description": "Endovasc prosth delayed", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33889", "type": "HCPCS" } ], "description": "Artery transpose/endovas taa", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33891", "type": "HCPCS" } ], "description": "Car-car bp grft/endovas taa", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33894", "type": "HCPCS" } ], "description": "Evasc st rpr thrc/aa acrs br", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33895", "type": "HCPCS" } ], "description": "Evasc st rpr thrc/aa x crsg", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33897", "type": "HCPCS" } ], "description": "Perq trluml angp nt/recr coa", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33900", "type": "HCPCS" } ], "description": "Perq p-art revsc 1 nm nt uni", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33901", "type": "HCPCS" } ], "description": "Perq p-art revsc 1 nm nt bi", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33902", "type": "HCPCS" } ], "description": "Perq p-art revsc 1 abnor uni", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33903", "type": "HCPCS" } ], "description": "Perq p-art revsc 1 abnor bi", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33910", "type": "HCPCS" } ], "description": "Remove lung artery emboli", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33915", "type": "HCPCS" } ], "description": "Remove lung artery emboli", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33916", "type": "HCPCS" } ], "description": "Surgery of great vessel", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33917", "type": "HCPCS" } ], "description": "Repair pulmonary artery", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33920", "type": "HCPCS" } ], "description": "Repair pulmonary atresia", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33922", "type": "HCPCS" } ], "description": "Transect pulmonary artery", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33924", "type": "HCPCS" } ], "description": "Remove pulmonary shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33925", "type": "HCPCS" } ], "description": "Rpr pul art unifocal w/o cpb", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33926", "type": "HCPCS" } ], "description": "Repr pul art unifocal w/cpb", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33927", "type": "HCPCS" } ], "description": "Impltj tot rplcmt hrt sys", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33928", "type": "HCPCS" } ], "description": "Rmvl & rplcmt tot hrt sys", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33929", "type": "HCPCS" } ], "description": "Rmvl rplcmt hrt sys f/trnspl", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33930", "type": "HCPCS" } ], "description": "Removal of donor heart/lung", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33933", "type": "HCPCS" } ], "description": "Prepare donor heart/lung", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33935", "type": "HCPCS" } ], "description": "Transplantation heart/lung", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33940", "type": "HCPCS" } ], "description": "Removal of donor heart", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33944", "type": "HCPCS" } ], "description": "Prepare donor heart", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33945", "type": "HCPCS" } ], "description": "Transplantation of heart", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33946", "type": "HCPCS" } ], "description": "Ecmo/ecls initiation venous", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33947", "type": "HCPCS" } ], "description": "Ecmo/ecls initiation artery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33948", "type": "HCPCS" } ], "description": "Ecmo/ecls daily mgmt-venous", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33949", "type": "HCPCS" } ], "description": "Ecmo/ecls daily mgmt artery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33951", "type": "HCPCS" } ], "description": "Ecmo/ecls insj prph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33952", "type": "HCPCS" } ], "description": "Ecmo/ecls insj prph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33953", "type": "HCPCS" } ], "description": "Ecmo/ecls insj prph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33954", "type": "HCPCS" } ], "description": "Ecmo/ecls insj prph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33955", "type": "HCPCS" } ], "description": "Ecmo/ecls insj ctr cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33956", "type": "HCPCS" } ], "description": "Ecmo/ecls insj ctr cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33957", "type": "HCPCS" } ], "description": "Ecmo/ecls repos perph cnula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33958", "type": "HCPCS" } ], "description": "Ecmo/ecls repos perph cnula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33959", "type": "HCPCS" } ], "description": "Ecmo/ecls repos perph cnula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33962", "type": "HCPCS" } ], "description": "Ecmo/ecls repos perph cnula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33963", "type": "HCPCS" } ], "description": "Ecmo/ecls repos perph cnula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33964", "type": "HCPCS" } ], "description": "Ecmo/ecls repos perph cnula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33965", "type": "HCPCS" } ], "description": "Ecmo/ecls rmvl perph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33966", "type": "HCPCS" } ], "description": "Ecmo/ecls rmvl prph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33967", "type": "HCPCS" } ], "description": "Insert i-aort percut device", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33968", "type": "HCPCS" } ], "description": "Remove aortic assist device", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33969", "type": "HCPCS" } ], "description": "Ecmo/ecls rmvl perph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33970", "type": "HCPCS" } ], "description": "Aortic circulation assist", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33971", "type": "HCPCS" } ], "description": "Aortic circulation assist", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33973", "type": "HCPCS" } ], "description": "Insert balloon device", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33974", "type": "HCPCS" } ], "description": "Remove intra-aortic balloon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33975", "type": "HCPCS" } ], "description": "Implant ventricular device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33976", "type": "HCPCS" } ], "description": "Implant ventricular device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33977", "type": "HCPCS" } ], "description": "Remove ventricular device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33978", "type": "HCPCS" } ], "description": "Remove ventricular device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33979", "type": "HCPCS" } ], "description": "Insert intracorporeal device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33980", "type": "HCPCS" } ], "description": "Remove intracorporeal device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33981", "type": "HCPCS" } ], "description": "Replace vad pump ext", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33982", "type": "HCPCS" } ], "description": "Replace vad intra w/o bp", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33983", "type": "HCPCS" } ], "description": "Replace vad intra w/bp", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33984", "type": "HCPCS" } ], "description": "Ecmo/ecls rmvl prph cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33985", "type": "HCPCS" } ], "description": "Ecmo/ecls rmvl ctr cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33986", "type": "HCPCS" } ], "description": "Ecmo/ecls rmvl ctr cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33987", "type": "HCPCS" } ], "description": "Artery expos/graft artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33988", "type": "HCPCS" } ], "description": "Insertion of left heart vent", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33989", "type": "HCPCS" } ], "description": "Removal of left heart vent", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33990", "type": "HCPCS" } ], "description": "Insert vad artery access", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33991", "type": "HCPCS" } ], "description": "Insert vad art&vein access", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33992", "type": "HCPCS" } ], "description": "Remove vad different session", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33993", "type": "HCPCS" } ], "description": "Reposition vad diff session", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33995", "type": "HCPCS" } ], "description": "Insj perq vad r hrt venous", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33997", "type": "HCPCS" } ], "description": "Rmvl perq right heart vad", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "33999", "type": "HCPCS" } ], "description": "Cardiac surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34001", "type": "HCPCS" } ], "description": "Removal of artery clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34051", "type": "HCPCS" } ], "description": "Removal of artery clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34101", "type": "HCPCS" } ], "description": "Removal of artery clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34111", "type": "HCPCS" } ], "description": "Removal of arm artery clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34151", "type": "HCPCS" } ], "description": "Removal of artery clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34201", "type": "HCPCS" } ], "description": "Removal of artery clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34203", "type": "HCPCS" } ], "description": "Removal of leg artery clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34401", "type": "HCPCS" } ], "description": "Removal of vein clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34421", "type": "HCPCS" } ], "description": "Removal of vein clot", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34451", "type": "HCPCS" } ], "description": "Removal of vein clot", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34471", "type": "HCPCS" } ], "description": "Removal of vein clot", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34490", "type": "HCPCS" } ], "description": "Removal of vein clot", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34501", "type": "HCPCS" } ], "description": "Repair valve femoral vein", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34502", "type": "HCPCS" } ], "description": "Reconstruct vena cava", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34510", "type": "HCPCS" } ], "description": "Transposition of vein valve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34520", "type": "HCPCS" } ], "description": "Cross-over vein graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34530", "type": "HCPCS" } ], "description": "Leg vein fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34701", "type": "HCPCS" } ], "description": "Evasc rpr a-ao ndgft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34702", "type": "HCPCS" } ], "description": "Evasc rpr a-ao ndgft rpt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34703", "type": "HCPCS" } ], "description": "Evasc rpr a-unilac ndgft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34704", "type": "HCPCS" } ], "description": "Evasc rpr a-unilac ndgft rpt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34705", "type": "HCPCS" } ], "description": "Evac rpr a-biiliac ndgft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34706", "type": "HCPCS" } ], "description": "Evasc rpr a-biiliac rpt", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34707", "type": "HCPCS" } ], "description": "Evasc rpr ilio-iliac ndgft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34708", "type": "HCPCS" } ], "description": "Evasc rpr ilio-iliac rpt", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34709", "type": "HCPCS" } ], "description": "Plmt xtn prosth evasc rpr", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34710", "type": "HCPCS" } ], "description": "Dlyd plmt xtn prosth 1st vsl", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34711", "type": "HCPCS" } ], "description": "Dlyd plmt xtn prosth ea addl", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34712", "type": "HCPCS" } ], "description": "Tcat dlvr enhncd fixj dev", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34717", "type": "HCPCS" } ], "description": "Evasc rpr a-iliac ndgft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34718", "type": "HCPCS" } ], "description": "Evasc rpr n/a a-iliac ndgft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34808", "type": "HCPCS" } ], "description": "Endovas iliac a device addon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34812", "type": "HCPCS" } ], "description": "Xpose for endoprosth femorl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34813", "type": "HCPCS" } ], "description": "Femoral endovas graft add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34820", "type": "HCPCS" } ], "description": "Xpose for endoprosth iliac", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34830", "type": "HCPCS" } ], "description": "Open Aortic Tube Prosth Repr", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34831", "type": "HCPCS" } ], "description": "Open Aortoiliac Prosth Repr", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34832", "type": "HCPCS" } ], "description": "Open Aortofemor Prosth Repr", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34833", "type": "HCPCS" } ], "description": "Xpose for endoprosth iliac", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34834", "type": "HCPCS" } ], "description": "Xpose endoprosth brachial", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34839", "type": "HCPCS" } ], "description": "Plnning pt spec fenest graft", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34841", "type": "HCPCS" } ], "description": "Endovasc visc aorta 1 graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34842", "type": "HCPCS" } ], "description": "Endovasc visc aorta 2 graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34843", "type": "HCPCS" } ], "description": "Endovasc visc aorta 3 graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34844", "type": "HCPCS" } ], "description": "Endovasc visc aorta 4 graft", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34845", "type": "HCPCS" } ], "description": "Visc & infraren abd 1 prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34846", "type": "HCPCS" } ], "description": "Visc & infraren abd 2 prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34847", "type": "HCPCS" } ], "description": "Visc & infraren abd 3 prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "34848", "type": "HCPCS" } ], "description": "Visc & infraren abd 4+ prost", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35001", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35002", "type": "HCPCS" } ], "description": "Repair artery rupture neck", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35005", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35011", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35013", "type": "HCPCS" } ], "description": "Repair artery rupture arm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35021", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35022", "type": "HCPCS" } ], "description": "Repair artery rupture chest", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35045", "type": "HCPCS" } ], "description": "Repair defect of arm artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35081", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35082", "type": "HCPCS" } ], "description": "Repair artery rupture aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35091", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35092", "type": "HCPCS" } ], "description": "Repair artery rupture aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35102", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35103", "type": "HCPCS" } ], "description": "Repair artery rupture aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35111", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35112", "type": "HCPCS" } ], "description": "Repair artery rupture spleen", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35121", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35122", "type": "HCPCS" } ], "description": "Repair artery rupture belly", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35131", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35132", "type": "HCPCS" } ], "description": "Repair artery rupture groin", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35141", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35142", "type": "HCPCS" } ], "description": "Repair artery rupture thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35151", "type": "HCPCS" } ], "description": "Repair defect of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35152", "type": "HCPCS" } ], "description": "Repair ruptd popliteal art", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35180", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35182", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35184", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35188", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35189", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35190", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35201", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35206", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35207", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35211", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35216", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35221", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35226", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35231", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35236", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35241", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35246", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35251", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35256", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35261", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35266", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35271", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35276", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35281", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35286", "type": "HCPCS" } ], "description": "Repair blood vessel lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35301", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35302", "type": "HCPCS" } ], "description": "Rechanneling of Artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35303", "type": "HCPCS" } ], "description": "Rechanneling of Artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35304", "type": "HCPCS" } ], "description": "Rechanneling of Artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35305", "type": "HCPCS" } ], "description": "Rechanneling of Artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35306", "type": "HCPCS" } ], "description": "Rechanneling of Artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35311", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35321", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35331", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35341", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35351", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35355", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35361", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35363", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35371", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35372", "type": "HCPCS" } ], "description": "Rechanneling of artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35390", "type": "HCPCS" } ], "description": "Reoperation carotid add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35400", "type": "HCPCS" } ], "description": "Angioscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35501", "type": "HCPCS" } ], "description": "Art byp grft ipsilat carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35506", "type": "HCPCS" } ], "description": "Art byp grft subclav-carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35508", "type": "HCPCS" } ], "description": "Art byp grft carotid-vertbrl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35509", "type": "HCPCS" } ], "description": "Art byp grft contral carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35510", "type": "HCPCS" } ], "description": "Art byp grft carotid-brchial", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35511", "type": "HCPCS" } ], "description": "Art byp grft subclav-subclav", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35512", "type": "HCPCS" } ], "description": "Art byp grft subclav-brchial", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35515", "type": "HCPCS" } ], "description": "Art byp grft subclav-vertbrl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35516", "type": "HCPCS" } ], "description": "Art byp grft subclav-axilary", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35518", "type": "HCPCS" } ], "description": "Art byp grft axillary-axilry", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35521", "type": "HCPCS" } ], "description": "Art byp grft axill-femoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35522", "type": "HCPCS" } ], "description": "Art byp grft axill-brachial", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35523", "type": "HCPCS" } ], "description": "Art byp grft brchl-ulnr-rdl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35525", "type": "HCPCS" } ], "description": "Art byp grft brachial-brchl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35526", "type": "HCPCS" } ], "description": "Art byp grft aor/carot/innom", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35531", "type": "HCPCS" } ], "description": "Art byp grft aorcel/aormesen", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35533", "type": "HCPCS" } ], "description": "Art byp grft axill/fem/fem", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35535", "type": "HCPCS" } ], "description": "Art byp grft hepatorenal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35536", "type": "HCPCS" } ], "description": "Art byp grft splenorenal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35537", "type": "HCPCS" } ], "description": "Art byp grft aortoiliac", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35538", "type": "HCPCS" } ], "description": "Art byp grft aortobi-iliac", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35539", "type": "HCPCS" } ], "description": "Art byp grft aortofemoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35540", "type": "HCPCS" } ], "description": "Art byp grft aortbifemoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35556", "type": "HCPCS" } ], "description": "Art byp grft fem-popliteal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35558", "type": "HCPCS" } ], "description": "Art byp grft fem-femoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35560", "type": "HCPCS" } ], "description": "Art byp grft aortorenal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35563", "type": "HCPCS" } ], "description": "Art byp grft ilioiliac", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35565", "type": "HCPCS" } ], "description": "Art byp grft iliofemoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35566", "type": "HCPCS" } ], "description": "Art byp fem-ant-post tib/prl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35570", "type": "HCPCS" } ], "description": "Art byp tibial-tib/peroneal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35571", "type": "HCPCS" } ], "description": "Art byp pop-tibl-prl-other", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35583", "type": "HCPCS" } ], "description": "Vein byp grft fem-popliteal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35585", "type": "HCPCS" } ], "description": "Vein byp fem-tibial peroneal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35587", "type": "HCPCS" } ], "description": "Vein byp pop-tibl peroneal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35600", "type": "HCPCS" } ], "description": "Harvest art for cabg add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35601", "type": "HCPCS" } ], "description": "Art byp common ipsi carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35606", "type": "HCPCS" } ], "description": "Art byp carotid-subclavian", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35612", "type": "HCPCS" } ], "description": "Art byp subclav-subclavian", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35616", "type": "HCPCS" } ], "description": "Art byp subclav-axillary", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35621", "type": "HCPCS" } ], "description": "Art byp axillary-femoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35623", "type": "HCPCS" } ], "description": "Art byp axillary-pop-tibial", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35626", "type": "HCPCS" } ], "description": "Art byp aorsubcl/carot/innom", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35631", "type": "HCPCS" } ], "description": "Art byp aor-celiac-msn-renal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35632", "type": "HCPCS" } ], "description": "Art byp ilio-celiac", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35633", "type": "HCPCS" } ], "description": "Art byp ilio-mesenteric", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35634", "type": "HCPCS" } ], "description": "Art byp iliorenal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35636", "type": "HCPCS" } ], "description": "Art byp spenorenal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35637", "type": "HCPCS" } ], "description": "Art byp aortoiliac", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35638", "type": "HCPCS" } ], "description": "Art byp aortobi-iliac", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35642", "type": "HCPCS" } ], "description": "Art byp carotid-vertebral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35645", "type": "HCPCS" } ], "description": "Art byp subclav-vertebrl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35646", "type": "HCPCS" } ], "description": "Art byp aortobifemoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35647", "type": "HCPCS" } ], "description": "Art byp aortofemoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35650", "type": "HCPCS" } ], "description": "Art byp axillary-axillary", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35654", "type": "HCPCS" } ], "description": "Art byp axill-fem-femoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35656", "type": "HCPCS" } ], "description": "Art byp femoral-popliteal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35661", "type": "HCPCS" } ], "description": "Art byp femoral-femoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35663", "type": "HCPCS" } ], "description": "Art byp ilioiliac", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35665", "type": "HCPCS" } ], "description": "Art byp iliofemoral", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35666", "type": "HCPCS" } ], "description": "Art byp fem-ant-post tib/prl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35671", "type": "HCPCS" } ], "description": "Art byp pop-tibl-prl-other", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35681", "type": "HCPCS" } ], "description": "Composite byp grft pros&vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35682", "type": "HCPCS" } ], "description": "Composite byp grft 2 veins", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35683", "type": "HCPCS" } ], "description": "Composite byp grft 3/> segmt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35691", "type": "HCPCS" } ], "description": "Art trnsposj vertbrl carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35693", "type": "HCPCS" } ], "description": "Art trnsposj subclavian", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35694", "type": "HCPCS" } ], "description": "Art trnsposj subclav carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35695", "type": "HCPCS" } ], "description": "Art trnsposj carotid subclav", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35697", "type": "HCPCS" } ], "description": "Reimplant artery each", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35700", "type": "HCPCS" } ], "description": "Reoperation bypass graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35701", "type": "HCPCS" } ], "description": "Exploration carotid artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35702", "type": "HCPCS" } ], "description": "Expl n/flwd surg uxtr art", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35703", "type": "HCPCS" } ], "description": "Expl n/flwd surg lxtr art", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35800", "type": "HCPCS" } ], "description": "Explore neck vessels", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35820", "type": "HCPCS" } ], "description": "Explore chest vessels", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35840", "type": "HCPCS" } ], "description": "Explore abdominal vessels", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35860", "type": "HCPCS" } ], "description": "Explore limb vessels", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35870", "type": "HCPCS" } ], "description": "Repair vessel graft defect", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35875", "type": "HCPCS" } ], "description": "Removal of clot in graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35876", "type": "HCPCS" } ], "description": "Removal of clot in graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35879", "type": "HCPCS" } ], "description": "Revise graft w/vein", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35881", "type": "HCPCS" } ], "description": "Revise graft w/vein", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35883", "type": "HCPCS" } ], "description": "Revise Graft w/Nonauto Graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35884", "type": "HCPCS" } ], "description": "Revise graft w/vein", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35901", "type": "HCPCS" } ], "description": "Excision graft neck", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35903", "type": "HCPCS" } ], "description": "Excision graft extremity", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35905", "type": "HCPCS" } ], "description": "Excision graft thorax", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "35907", "type": "HCPCS" } ], "description": "Excision graft abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36002", "type": "HCPCS" } ], "description": "Pseudoaneurysm injection trt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36221", "type": "HCPCS" } ], "description": "Place cath thoracic aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36222", "type": "HCPCS" } ], "description": "Place cath carotid/inom art", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36223", "type": "HCPCS" } ], "description": "Place cath carotid/inom art", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36224", "type": "HCPCS" } ], "description": "Place cath carotd art", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36225", "type": "HCPCS" } ], "description": "Place cath subclavian art", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36226", "type": "HCPCS" } ], "description": "Place cath vertebral art", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36251", "type": "HCPCS" } ], "description": "Ins cath ren art 1st unilat", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36252", "type": "HCPCS" } ], "description": "Ins cath ren art 1st bilat", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36253", "type": "HCPCS" } ], "description": "Ins cath ren art 2nd+ unilat", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36254", "type": "HCPCS" } ], "description": "Ins cath ren art 2nd+ bilat", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36260", "type": "HCPCS" } ], "description": "Insertion of infusion pump", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36261", "type": "HCPCS" } ], "description": "Revision of infusion pump", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36262", "type": "HCPCS" } ], "description": "Removal of infusion pump", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3603.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3603.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36420", "type": "HCPCS" } ], "description": "Vein access cutdown < 1 yr", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36425", "type": "HCPCS" } ], "description": "Vein access cutdown > 1 yr", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36430", "type": "HCPCS" } ], "description": "Blood transfusion service", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36440", "type": "HCPCS" } ], "description": "Bl push transfuse 2 yr/<", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36450", "type": "HCPCS" } ], "description": "Bl exchange/transfuse nb", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36455", "type": "HCPCS" } ], "description": "Bl exchange/transfuse non-nb", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36456", "type": "HCPCS" } ], "description": "Prtl exchange transfuse nb", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36460", "type": "HCPCS" } ], "description": "Transfusion service fetal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36465", "type": "HCPCS" } ], "description": "Njx noncmpnd sclrsnt 1 vein", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36466", "type": "HCPCS" } ], "description": "Njx noncmpnd sclrsnt mlt vn", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36468", "type": "HCPCS" } ], "description": "Injection(s) spider veins", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36470", "type": "HCPCS" } ], "description": "Injection therapy of vein", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36471", "type": "HCPCS" } ], "description": "Injection therapy of veins", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36473", "type": "HCPCS" } ], "description": "Endovenous mchnchem 1st vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36475", "type": "HCPCS" } ], "description": "Endovenous rf 1st vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36478", "type": "HCPCS" } ], "description": "Endovenous laser 1st vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36482", "type": "HCPCS" } ], "description": "Endoven ther chem adhes 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36511", "type": "HCPCS" } ], "description": "Apheresis wbc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36512", "type": "HCPCS" } ], "description": "Apheresis rbc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36513", "type": "HCPCS" } ], "description": "Apheresis platelets", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36514", "type": "HCPCS" } ], "description": "Apheresis plasma", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36516", "type": "HCPCS" } ], "description": "Apheresis selective", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4199.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4199.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36522", "type": "HCPCS" } ], "description": "Photopheresis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4199.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4199.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36555", "type": "HCPCS" } ], "description": "Insert non-tunnel cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36556", "type": "HCPCS" } ], "description": "Insert non-tunnel cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36557", "type": "HCPCS" } ], "description": "Insert tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36558", "type": "HCPCS" } ], "description": "Insert tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36560", "type": "HCPCS" } ], "description": "Insert tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36561", "type": "HCPCS" } ], "description": "Insert tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36563", "type": "HCPCS" } ], "description": "Insert tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36565", "type": "HCPCS" } ], "description": "Insert tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36566", "type": "HCPCS" } ], "description": "Insert tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36568", "type": "HCPCS" } ], "description": "Insert picc cath", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36569", "type": "HCPCS" } ], "description": "Insert picc cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36570", "type": "HCPCS" } ], "description": "Insert picvad cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36571", "type": "HCPCS" } ], "description": "Insert picvad cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36572", "type": "HCPCS" } ], "description": "Insj picc rs&i <5 yr", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36573", "type": "HCPCS" } ], "description": "Insj picc rs&i 5 yr+", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36575", "type": "HCPCS" } ], "description": "Repair tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36576", "type": "HCPCS" } ], "description": "Repair tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36578", "type": "HCPCS" } ], "description": "Replace tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36580", "type": "HCPCS" } ], "description": "Replace cvad cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36581", "type": "HCPCS" } ], "description": "Replace tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36582", "type": "HCPCS" } ], "description": "Replace tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36583", "type": "HCPCS" } ], "description": "Replace tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36584", "type": "HCPCS" } ], "description": "Replace picc cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36585", "type": "HCPCS" } ], "description": "Replace picvad cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36589", "type": "HCPCS" } ], "description": "Removal tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36590", "type": "HCPCS" } ], "description": "Removal tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36593", "type": "HCPCS" } ], "description": "Declot vascular device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36595", "type": "HCPCS" } ], "description": "Mech remov tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36596", "type": "HCPCS" } ], "description": "Mech remov tunneled cv cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36597", "type": "HCPCS" } ], "description": "Reposition venous catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36598", "type": "HCPCS" } ], "description": "Inj w/fluor eval cv device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36600", "type": "HCPCS" } ], "description": "Withdrawal of arterial blood", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36640", "type": "HCPCS" } ], "description": "Insertion catheter artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36660", "type": "HCPCS" } ], "description": "Insertion catheter artery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36680", "type": "HCPCS" } ], "description": "Insert needle bone cavity", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36800", "type": "HCPCS" } ], "description": "Insertion of cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36810", "type": "HCPCS" } ], "description": "Insertion of cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36815", "type": "HCPCS" } ], "description": "Insertion of cannula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36818", "type": "HCPCS" } ], "description": "Av fuse uppr arm cephalic", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36819", "type": "HCPCS" } ], "description": "Av fuse uppr arm basilic", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36820", "type": "HCPCS" } ], "description": "Av fusion/forearm vein", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36821", "type": "HCPCS" } ], "description": "Av fusion direct any site", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36823", "type": "HCPCS" } ], "description": "Insertion of cannula(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36825", "type": "HCPCS" } ], "description": "Artery-vein autograft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36830", "type": "HCPCS" } ], "description": "Artery-vein nonautograft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36831", "type": "HCPCS" } ], "description": "Open thrombect av fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36832", "type": "HCPCS" } ], "description": "Av fistula revision open", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36833", "type": "HCPCS" } ], "description": "Av fistula revision", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36835", "type": "HCPCS" } ], "description": "Artery to vein shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36836", "type": "HCPCS" } ], "description": "Prq av fstl crtj uxtr 1 acs", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36837", "type": "HCPCS" } ], "description": "Prq av fstl crt uxtr sep acs", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36838", "type": "HCPCS" } ], "description": "Dist revas ligation hemo", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36860", "type": "HCPCS" } ], "description": "External cannula declotting", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36861", "type": "HCPCS" } ], "description": "Cannula declotting", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36901", "type": "HCPCS" } ], "description": "Intro cath dialysis circuit", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36902", "type": "HCPCS" } ], "description": "Intro cath dialysis circuit", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36903", "type": "HCPCS" } ], "description": "Intro cath dialysis circuit", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36904", "type": "HCPCS" } ], "description": "Thrmbc/nfs dialysis circuit", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36905", "type": "HCPCS" } ], "description": "Thrmbc/nfs dialysis circuit", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36906", "type": "HCPCS" } ], "description": "Thrmbc/nfs dialysis circuit", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37140", "type": "HCPCS" } ], "description": "Revision of circulation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37145", "type": "HCPCS" } ], "description": "Revision of circulation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37160", "type": "HCPCS" } ], "description": "Revision of circulation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37180", "type": "HCPCS" } ], "description": "Revision of circulation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37181", "type": "HCPCS" } ], "description": "Splice spleen/kidney veins", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37182", "type": "HCPCS" } ], "description": "Insert hepatic shunt (tips)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37183", "type": "HCPCS" } ], "description": "Remove hepatic shunt (tips)", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37184", "type": "HCPCS" } ], "description": "Prim art m-thrmbc 1st vsl", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37187", "type": "HCPCS" } ], "description": "Venous mech thrombectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37188", "type": "HCPCS" } ], "description": "Venous m-thrombectomy add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37191", "type": "HCPCS" } ], "description": "Ins endovas vena cava filtr", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37192", "type": "HCPCS" } ], "description": "Redo endovas vena cava filtr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37193", "type": "HCPCS" } ], "description": "Rem endovas vena cava filter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37195", "type": "HCPCS" } ], "description": "Thrombolytic therapy stroke", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37197", "type": "HCPCS" } ], "description": "Remove intrvas foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37200", "type": "HCPCS" } ], "description": "Transcatheter biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37211", "type": "HCPCS" } ], "description": "Thrombolytic art therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37212", "type": "HCPCS" } ], "description": "Thrombolytic venous therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37213", "type": "HCPCS" } ], "description": "Thromblytic art/ven therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37214", "type": "HCPCS" } ], "description": "Cessj therapy cath removal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37215", "type": "HCPCS" } ], "description": "Transcath stent cca w/eps", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37216", "type": "HCPCS" } ], "description": "Transcath stent cca w/o eps", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37217", "type": "HCPCS" } ], "description": "Stent placemt retro carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37218", "type": "HCPCS" } ], "description": "Stent placemt ante carotid", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37220", "type": "HCPCS" } ], "description": "Iliac revasc", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37221", "type": "HCPCS" } ], "description": "Iliac revasc w/stent", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37224", "type": "HCPCS" } ], "description": "Fem/popl revas w/tla", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37225", "type": "HCPCS" } ], "description": "Fem/popl revas w/ather", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37226", "type": "HCPCS" } ], "description": "Fem/popl revasc w/stent", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37227", "type": "HCPCS" } ], "description": "Fem/popl revasc stnt & ather", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37228", "type": "HCPCS" } ], "description": "Tib/per revasc w/tla", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37229", "type": "HCPCS" } ], "description": "Tib/per revasc w/ather", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37230", "type": "HCPCS" } ], "description": "Tib/per revasc w/stent", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37231", "type": "HCPCS" } ], "description": "Tib/per revasc stent & ather", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37236", "type": "HCPCS" } ], "description": "Open/perq place stent 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37238", "type": "HCPCS" } ], "description": "Open/perq place stent same", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37241", "type": "HCPCS" } ], "description": "Vasc embolize/occlude venous", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37242", "type": "HCPCS" } ], "description": "Vasc embolize/occlude artery", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37243", "type": "HCPCS" } ], "description": "Vasc embolize/occlude organ", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37244", "type": "HCPCS" } ], "description": "Vasc embolize/occlude bleed", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37246", "type": "HCPCS" } ], "description": "Trluml balo angiop 1st art", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37248", "type": "HCPCS" } ], "description": "Trluml balo angiop 1st vein", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37500", "type": "HCPCS" } ], "description": "Endoscopy ligate perf veins", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37501", "type": "HCPCS" } ], "description": "Vascular endoscopy procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37565", "type": "HCPCS" } ], "description": "Ligation of neck vein", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37600", "type": "HCPCS" } ], "description": "Ligation of neck artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37605", "type": "HCPCS" } ], "description": "Ligation of neck artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37606", "type": "HCPCS" } ], "description": "Ligation of neck artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37607", "type": "HCPCS" } ], "description": "Ligation of a-v fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37609", "type": "HCPCS" } ], "description": "Temporal artery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37615", "type": "HCPCS" } ], "description": "Ligation of neck artery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37616", "type": "HCPCS" } ], "description": "Ligation of chest artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37617", "type": "HCPCS" } ], "description": "Ligation of abdomen artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37618", "type": "HCPCS" } ], "description": "Ligation of extremity artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37619", "type": "HCPCS" } ], "description": "Ligation of inf vena cava", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37650", "type": "HCPCS" } ], "description": "Revision of major vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37660", "type": "HCPCS" } ], "description": "Revision of major vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37700", "type": "HCPCS" } ], "description": "Revise leg vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37718", "type": "HCPCS" } ], "description": "Ligate/strip short leg vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37722", "type": "HCPCS" } ], "description": "Ligate/strip long leg vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37735", "type": "HCPCS" } ], "description": "Removal of leg veins/lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37760", "type": "HCPCS" } ], "description": "Ligate leg veins radical", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37761", "type": "HCPCS" } ], "description": "Ligate leg veins open", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37765", "type": "HCPCS" } ], "description": "Stab phleb veins xtr 10-20", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37766", "type": "HCPCS" } ], "description": "Phleb veins - extrem 20+", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37780", "type": "HCPCS" } ], "description": "Revision of leg vein", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37785", "type": "HCPCS" } ], "description": "Ligate/divide/excise vein", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37788", "type": "HCPCS" } ], "description": "Revascularization penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37790", "type": "HCPCS" } ], "description": "Penile venous occlusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37799", "type": "HCPCS" } ], "description": "Vascular surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38100", "type": "HCPCS" } ], "description": "Removal of spleen total", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38101", "type": "HCPCS" } ], "description": "Removal of spleen partial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38102", "type": "HCPCS" } ], "description": "Removal of spleen total", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38115", "type": "HCPCS" } ], "description": "Repair of ruptured spleen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38120", "type": "HCPCS" } ], "description": "Laparoscopy splenectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38129", "type": "HCPCS" } ], "description": "Laparoscope proc spleen", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38205", "type": "HCPCS" } ], "description": "Harvest allogeneic stem cell", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38206", "type": "HCPCS" } ], "description": "Harvest auto stem cells", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38207", "type": "HCPCS" } ], "description": "Cryopreserve stem cells", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38208", "type": "HCPCS" } ], "description": "Thaw preserved stem cells", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38209", "type": "HCPCS" } ], "description": "Wash harvest stem cells", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38210", "type": "HCPCS" } ], "description": "T-cell depletion of harvest", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38211", "type": "HCPCS" } ], "description": "Tumor cell deplete of harvst", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38212", "type": "HCPCS" } ], "description": "Rbc depletion of harvest", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38213", "type": "HCPCS" } ], "description": "Platelet deplete of harvest", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38214", "type": "HCPCS" } ], "description": "Volume deplete of harvest", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38215", "type": "HCPCS" } ], "description": "Harvest stem cell concentrte", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38220", "type": "HCPCS" } ], "description": "Bone marrow aspiration", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38221", "type": "HCPCS" } ], "description": "Bone marrow biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38222", "type": "HCPCS" } ], "description": "Dx bone marrow bx & aspir", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38230", "type": "HCPCS" } ], "description": "Bone marrow harvest allogen", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38232", "type": "HCPCS" } ], "description": "Bone marrow harvest autolog", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4199.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4199.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38240", "type": "HCPCS" } ], "description": "Transplt allo hct/donor", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 60650.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60650.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38241", "type": "HCPCS" } ], "description": "Transplt autol hct/donor", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38242", "type": "HCPCS" } ], "description": "Transplt allo lymphocytes", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38243", "type": "HCPCS" } ], "description": "Transplj hematopoietic boost", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38300", "type": "HCPCS" } ], "description": "Drainage lymph node lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38305", "type": "HCPCS" } ], "description": "Drainage lymph node lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38308", "type": "HCPCS" } ], "description": "Incision of lymph channels", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38380", "type": "HCPCS" } ], "description": "Thoracic duct procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38381", "type": "HCPCS" } ], "description": "Thoracic duct procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38382", "type": "HCPCS" } ], "description": "Thoracic duct procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38500", "type": "HCPCS" } ], "description": "Biopsy/removal lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38505", "type": "HCPCS" } ], "description": "Needle biopsy lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38510", "type": "HCPCS" } ], "description": "Biopsy/removal lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38520", "type": "HCPCS" } ], "description": "Biopsy/removal lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38525", "type": "HCPCS" } ], "description": "Biopsy/removal lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38530", "type": "HCPCS" } ], "description": "Biopsy/removal lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38531", "type": "HCPCS" } ], "description": "Open bx/exc inguinofem nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38542", "type": "HCPCS" } ], "description": "Explore deep node(s) neck", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38550", "type": "HCPCS" } ], "description": "Removal neck/armpit lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38555", "type": "HCPCS" } ], "description": "Removal neck/armpit lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38562", "type": "HCPCS" } ], "description": "Removal pelvic lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 7880.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7880.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38564", "type": "HCPCS" } ], "description": "Removal abdomen lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38570", "type": "HCPCS" } ], "description": "Laparoscopy lymph node biop", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38571", "type": "HCPCS" } ], "description": "Laparoscopy lymphadenectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38572", "type": "HCPCS" } ], "description": "Laparoscopy lymphadenectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38573", "type": "HCPCS" } ], "description": "Laps pelvic lymphadec", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38589", "type": "HCPCS" } ], "description": "Laparoscope proc lymphatic", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38700", "type": "HCPCS" } ], "description": "Removal of lymph nodes neck", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38720", "type": "HCPCS" } ], "description": "Removal of lymph nodes neck", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38724", "type": "HCPCS" } ], "description": "Removal of lymph nodes neck", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38740", "type": "HCPCS" } ], "description": "Remove armpit lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38745", "type": "HCPCS" } ], "description": "Remove armpit lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38746", "type": "HCPCS" } ], "description": "Remove thoracic lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38747", "type": "HCPCS" } ], "description": "Remove abdominal lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38760", "type": "HCPCS" } ], "description": "Remove groin lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38765", "type": "HCPCS" } ], "description": "Remove groin lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38770", "type": "HCPCS" } ], "description": "Remove pelvis lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38780", "type": "HCPCS" } ], "description": "Remove abdomen lymph nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38792", "type": "HCPCS" } ], "description": "Ra tracer id of sentinl node", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "38999", "type": "HCPCS" } ], "description": "Blood/lymph system procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 425.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 425.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39000", "type": "HCPCS" } ], "description": "Exploration of chest", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39010", "type": "HCPCS" } ], "description": "Exploration of chest", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39200", "type": "HCPCS" } ], "description": "Resect mediastinal cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39220", "type": "HCPCS" } ], "description": "Resect mediastinal tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39401", "type": "HCPCS" } ], "description": "Mediastinoscpy w/medstnl bx", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39402", "type": "HCPCS" } ], "description": "Mediastinoscpy w/lmph nod bx", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39499", "type": "HCPCS" } ], "description": "Chest procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 16564.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39501", "type": "HCPCS" } ], "description": "Repair diaphragm laceration", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39503", "type": "HCPCS" } ], "description": "Repair of diaphragm hernia", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39540", "type": "HCPCS" } ], "description": "Repair of diaphragm hernia", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39541", "type": "HCPCS" } ], "description": "Repair of diaphragm hernia", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39545", "type": "HCPCS" } ], "description": "Revision of diaphragm", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39560", "type": "HCPCS" } ], "description": "Resect diaphragm simple", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39561", "type": "HCPCS" } ], "description": "Resect diaphragm complex", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "39599", "type": "HCPCS" } ], "description": "Diaphragm surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 16564.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40490", "type": "HCPCS" } ], "description": "Biopsy of lip", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40500", "type": "HCPCS" } ], "description": "Partial excision of lip", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40510", "type": "HCPCS" } ], "description": "Partial excision of lip", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40520", "type": "HCPCS" } ], "description": "Partial excision of lip", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40525", "type": "HCPCS" } ], "description": "Reconstruct lip with flap", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40527", "type": "HCPCS" } ], "description": "Reconstruct lip with flap", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40530", "type": "HCPCS" } ], "description": "Partial removal of lip", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40650", "type": "HCPCS" } ], "description": "Repair lip", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40652", "type": "HCPCS" } ], "description": "Repair lip", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40654", "type": "HCPCS" } ], "description": "Repair lip", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40700", "type": "HCPCS" } ], "description": "Repair cleft lip/nasal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40701", "type": "HCPCS" } ], "description": "Repair cleft lip/nasal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40702", "type": "HCPCS" } ], "description": "Repair cleft lip/nasal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40720", "type": "HCPCS" } ], "description": "Repair cleft lip/nasal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40761", "type": "HCPCS" } ], "description": "Repair cleft lip/nasal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40799", "type": "HCPCS" } ], "description": "Lip surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40800", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40801", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40804", "type": "HCPCS" } ], "description": "Removal foreign body mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40805", "type": "HCPCS" } ], "description": "Removal foreign body mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40806", "type": "HCPCS" } ], "description": "Incision of lip fold", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40808", "type": "HCPCS" } ], "description": "Biopsy of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40810", "type": "HCPCS" } ], "description": "Excision of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40812", "type": "HCPCS" } ], "description": "Excise/repair mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40814", "type": "HCPCS" } ], "description": "Excise/repair mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40816", "type": "HCPCS" } ], "description": "Excision of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40818", "type": "HCPCS" } ], "description": "Excise oral mucosa for graft", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40819", "type": "HCPCS" } ], "description": "Excise lip or cheek fold", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40820", "type": "HCPCS" } ], "description": "Treatment of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40830", "type": "HCPCS" } ], "description": "Repair mouth laceration", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40831", "type": "HCPCS" } ], "description": "Repair mouth laceration", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40840", "type": "HCPCS" } ], "description": "Reconstruction of mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40842", "type": "HCPCS" } ], "description": "Reconstruction of mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40843", "type": "HCPCS" } ], "description": "Reconstruction of mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40844", "type": "HCPCS" } ], "description": "Reconstruction of mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40845", "type": "HCPCS" } ], "description": "Reconstruction of mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "40899", "type": "HCPCS" } ], "description": "Mouth surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41000", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41005", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41006", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41007", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41008", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41009", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41010", "type": "HCPCS" } ], "description": "Incision of tongue fold", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41015", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41016", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41017", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41018", "type": "HCPCS" } ], "description": "Drainage of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41019", "type": "HCPCS" } ], "description": "Place needles h&n for rt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41100", "type": "HCPCS" } ], "description": "Biopsy of tongue", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41105", "type": "HCPCS" } ], "description": "Biopsy of tongue", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41108", "type": "HCPCS" } ], "description": "Biopsy of floor of mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41110", "type": "HCPCS" } ], "description": "Excision of tongue lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41112", "type": "HCPCS" } ], "description": "Excision of tongue lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41113", "type": "HCPCS" } ], "description": "Excision of tongue lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41114", "type": "HCPCS" } ], "description": "Excision of tongue lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41115", "type": "HCPCS" } ], "description": "Excision of tongue fold", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41116", "type": "HCPCS" } ], "description": "Excision of mouth lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41120", "type": "HCPCS" } ], "description": "Partial removal of tongue", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41130", "type": "HCPCS" } ], "description": "Partial removal of tongue", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41135", "type": "HCPCS" } ], "description": "Tongue and neck surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41140", "type": "HCPCS" } ], "description": "Removal of tongue", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41145", "type": "HCPCS" } ], "description": "Tongue removal neck surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41150", "type": "HCPCS" } ], "description": "Tongue mouth jaw surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41153", "type": "HCPCS" } ], "description": "Tongue mouth neck surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41155", "type": "HCPCS" } ], "description": "Tongue jaw & neck surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41250", "type": "HCPCS" } ], "description": "Repair tongue laceration", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41251", "type": "HCPCS" } ], "description": "Repair tongue laceration", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41252", "type": "HCPCS" } ], "description": "Repair tongue laceration", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41510", "type": "HCPCS" } ], "description": "Tongue to lip surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41512", "type": "HCPCS" } ], "description": "Tongue suspension", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41520", "type": "HCPCS" } ], "description": "Reconstruction tongue fold", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41530", "type": "HCPCS" } ], "description": "Tongue base vol reduction", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41599", "type": "HCPCS" } ], "description": "Tongue and mouth surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41800", "type": "HCPCS" } ], "description": "Drainage of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41805", "type": "HCPCS" } ], "description": "Removal foreign body gum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41806", "type": "HCPCS" } ], "description": "Removal foreign body jawbone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41820", "type": "HCPCS" } ], "description": "Excision gum each quadrant", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41821", "type": "HCPCS" } ], "description": "Excision of gum flap", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41822", "type": "HCPCS" } ], "description": "Excision of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41823", "type": "HCPCS" } ], "description": "Excision of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41825", "type": "HCPCS" } ], "description": "Excision of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41826", "type": "HCPCS" } ], "description": "Excision of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41827", "type": "HCPCS" } ], "description": "Excision of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41828", "type": "HCPCS" } ], "description": "Excision of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41830", "type": "HCPCS" } ], "description": "Removal of gum tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41850", "type": "HCPCS" } ], "description": "Treatment of gum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41870", "type": "HCPCS" } ], "description": "Gum graft", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41872", "type": "HCPCS" } ], "description": "Repair gum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41874", "type": "HCPCS" } ], "description": "Repair tooth socket", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "41899", "type": "HCPCS" } ], "description": "Dental surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42000", "type": "HCPCS" } ], "description": "Drainage mouth roof lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42100", "type": "HCPCS" } ], "description": "Biopsy roof of mouth", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42104", "type": "HCPCS" } ], "description": "Excision lesion mouth roof", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42106", "type": "HCPCS" } ], "description": "Excision lesion mouth roof", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42107", "type": "HCPCS" } ], "description": "Excision lesion mouth roof", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42120", "type": "HCPCS" } ], "description": "Remove palate/lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42140", "type": "HCPCS" } ], "description": "Excision of uvula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42145", "type": "HCPCS" } ], "description": "Repair palate pharynx/uvula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42160", "type": "HCPCS" } ], "description": "Treatment mouth roof lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42180", "type": "HCPCS" } ], "description": "Repair palate", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42182", "type": "HCPCS" } ], "description": "Repair palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42200", "type": "HCPCS" } ], "description": "Reconstruct cleft palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42205", "type": "HCPCS" } ], "description": "Reconstruct cleft palate", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42210", "type": "HCPCS" } ], "description": "Reconstruct cleft palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42215", "type": "HCPCS" } ], "description": "Reconstruct cleft palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42220", "type": "HCPCS" } ], "description": "Reconstruct cleft palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42225", "type": "HCPCS" } ], "description": "Reconstruct cleft palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42226", "type": "HCPCS" } ], "description": "Lengthening of palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42227", "type": "HCPCS" } ], "description": "Lengthening of palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42235", "type": "HCPCS" } ], "description": "Repair palate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42260", "type": "HCPCS" } ], "description": "Repair nose to lip fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42280", "type": "HCPCS" } ], "description": "Preparation palate mold", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42281", "type": "HCPCS" } ], "description": "Insertion palate prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42299", "type": "HCPCS" } ], "description": "Palate/uvula surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42300", "type": "HCPCS" } ], "description": "Drainage of salivary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42305", "type": "HCPCS" } ], "description": "Drainage of salivary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42310", "type": "HCPCS" } ], "description": "Drainage of salivary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42320", "type": "HCPCS" } ], "description": "Drainage of salivary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42330", "type": "HCPCS" } ], "description": "Removal of salivary stone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42335", "type": "HCPCS" } ], "description": "Removal of salivary stone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42340", "type": "HCPCS" } ], "description": "Removal of salivary stone", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42400", "type": "HCPCS" } ], "description": "Biopsy of salivary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42405", "type": "HCPCS" } ], "description": "Biopsy of salivary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42408", "type": "HCPCS" } ], "description": "Excision of salivary cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42409", "type": "HCPCS" } ], "description": "Drainage of salivary cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42410", "type": "HCPCS" } ], "description": "Excise parotid gland/lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42415", "type": "HCPCS" } ], "description": "Excise parotid gland/lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42420", "type": "HCPCS" } ], "description": "Excise parotid gland/lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42425", "type": "HCPCS" } ], "description": "Excise parotid gland/lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42426", "type": "HCPCS" } ], "description": "Excise parotid gland/lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42440", "type": "HCPCS" } ], "description": "Excise submaxillary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42450", "type": "HCPCS" } ], "description": "Excise sublingual gland", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42500", "type": "HCPCS" } ], "description": "Repair salivary duct", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42505", "type": "HCPCS" } ], "description": "Repair salivary duct", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42507", "type": "HCPCS" } ], "description": "Parotid duct diversion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42509", "type": "HCPCS" } ], "description": "Parotid duct diversion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42510", "type": "HCPCS" } ], "description": "Parotid duct diversion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42600", "type": "HCPCS" } ], "description": "Closure of salivary fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42650", "type": "HCPCS" } ], "description": "Dilation of salivary duct", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42660", "type": "HCPCS" } ], "description": "Dilation of salivary duct", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42665", "type": "HCPCS" } ], "description": "Ligation of salivary duct", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42699", "type": "HCPCS" } ], "description": "Salivary surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, 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"Drainage of throat abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42725", "type": "HCPCS" } ], "description": "Drainage of throat abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42800", "type": "HCPCS" } ], "description": "Biopsy of throat", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42804", "type": "HCPCS" } ], "description": "Biopsy of upper nose/throat", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42806", "type": "HCPCS" } ], "description": "Biopsy of upper nose/throat", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42808", "type": "HCPCS" } ], "description": "Excise pharynx lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42809", "type": "HCPCS" } ], "description": "Remove pharynx foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42810", "type": "HCPCS" } ], "description": "Excision of neck cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42815", "type": "HCPCS" } ], "description": "Excision of neck cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42820", "type": "HCPCS" } ], "description": "Remove tonsils and adenoids", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42821", "type": "HCPCS" } ], "description": "Remove tonsils and adenoids", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42825", "type": "HCPCS" } ], "description": "Removal of tonsils", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42826", "type": "HCPCS" } ], "description": "Removal of tonsils", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42830", "type": "HCPCS" } ], "description": "Removal of adenoids", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42831", "type": "HCPCS" } ], "description": "Removal of adenoids", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42835", "type": "HCPCS" } ], "description": "Removal of adenoids", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42836", "type": "HCPCS" } ], "description": "Removal of adenoids", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42842", "type": "HCPCS" } ], "description": "Extensive surgery of throat", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42844", "type": "HCPCS" } ], "description": "Extensive surgery of throat", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42845", "type": "HCPCS" } ], "description": "Extensive surgery of throat", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42860", "type": "HCPCS" } ], "description": "Excision of tonsil tags", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42870", "type": "HCPCS" } ], "description": "Excision of lingual tonsil", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42890", "type": "HCPCS" } ], "description": "Partial removal of pharynx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42892", "type": "HCPCS" } ], "description": "Revision of pharyngeal walls", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42894", "type": "HCPCS" } ], "description": "Revision of pharyngeal walls", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42900", "type": "HCPCS" } ], "description": "Repair throat wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42950", "type": "HCPCS" } ], "description": "Reconstruction of throat", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42953", "type": "HCPCS" } ], "description": "Repair throat esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42955", "type": "HCPCS" } ], "description": "Surgical opening of throat", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42960", "type": "HCPCS" } ], "description": "Control throat bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42961", "type": "HCPCS" } ], "description": "Control throat bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42962", "type": "HCPCS" } ], "description": "Control throat bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42970", "type": "HCPCS" } ], "description": "Control nose/throat bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42971", "type": "HCPCS" } ], "description": "Control nose/throat bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42972", "type": "HCPCS" } ], "description": "Control nose/throat bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42975", "type": "HCPCS" } ], "description": "Dise eval slp do brth flx dx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1716.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1716.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "42999", "type": "HCPCS" } ], "description": "Throat surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43020", "type": "HCPCS" } ], "description": "Incision of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43030", "type": "HCPCS" } ], "description": "Throat muscle surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43045", "type": "HCPCS" } ], "description": "Incision of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43100", "type": "HCPCS" } ], "description": "Excision of esophagus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43101", "type": "HCPCS" } ], "description": "Excision of esophagus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43107", "type": "HCPCS" } ], "description": "Removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43108", "type": "HCPCS" } ], "description": "Removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43112", "type": "HCPCS" } ], "description": "Removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43113", "type": "HCPCS" } ], "description": "Removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43116", "type": "HCPCS" } ], "description": "Partial removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43117", "type": "HCPCS" } ], "description": "Partial removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43118", "type": "HCPCS" } ], "description": "Partial removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43121", "type": "HCPCS" } ], "description": "Partial removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43122", "type": "HCPCS" } ], "description": "Partial removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43123", "type": "HCPCS" } ], "description": "Partial removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43124", "type": "HCPCS" } ], "description": "Removal of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43130", "type": "HCPCS" } ], "description": "Removal of esophagus pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43135", "type": "HCPCS" } ], "description": "Removal of esophagus pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43180", "type": "HCPCS" } ], "description": "Esophagoscopy rigid trnso", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43191", "type": "HCPCS" } ], "description": "Esophagoscopy rigid trnso dx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43192", "type": "HCPCS" } ], "description": "Esophagoscp rig trnso inject", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43193", "type": "HCPCS" } ], "description": "Esophagoscp rig trnso biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43194", "type": "HCPCS" } ], "description": "Esophagoscp rig trnso rem fb", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43195", "type": "HCPCS" } ], "description": "Esophagoscopy rigid balloon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43196", "type": "HCPCS" } ], "description": "Esophagoscp guide wire dilat", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43197", "type": "HCPCS" } ], "description": "Esophagoscopy flex dx brush", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43198", "type": "HCPCS" } ], "description": "Esophagosc flex trnsn biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43200", "type": "HCPCS" } ], "description": "Esophagoscopy flexible brush", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43201", "type": "HCPCS" } ], "description": "Esoph scope w/submucous inj", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43202", "type": "HCPCS" } ], "description": "Esophagoscopy flex biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43204", "type": "HCPCS" } ], "description": "Esoph scope w/sclerosis inj", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43205", "type": "HCPCS" } ], "description": "Esophagus endoscopy/ligation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43206", "type": "HCPCS" } ], "description": "Esoph optical endomicroscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43210", "type": "HCPCS" } ], "description": "Egd esophagogastrc fndoplsty", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43211", "type": "HCPCS" } ], "description": "Esophagoscop mucosal resect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43212", "type": "HCPCS" } ], "description": "Esophagoscop stent placement", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0001U", "type": "HCPCS" } ], "description": "Rbc dna hea 35 ag 11 bld grp", "standard_charges": [ { "billing_class": "facility", "maximum": 2700.0, "minimum": 720.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 720.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2700.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2700.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0002U", "type": "HCPCS" } ], "description": "Onc clrct 3 ur metab alg plp", "standard_charges": [ { "billing_class": "facility", "maximum": 93.75, "minimum": 25.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0003U", "type": "HCPCS" } ], "description": "Onc ovar 5 prtn ser alg scor", "standard_charges": [ { "billing_class": "facility", "maximum": 3562.5, "minimum": 950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3562.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3562.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0005U", "type": "HCPCS" } ], "description": "Onco prst8 3 gene ur alg", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0007U", "type": "HCPCS" } ], "description": "Rx test prsmv ur w/def conf", "standard_charges": [ { "billing_class": "facility", "maximum": 429.11, "minimum": 114.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 429.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 429.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0008U", "type": "HCPCS" } ], "description": "Hpylori detcj abx rstnc dna", "standard_charges": [ { "billing_class": "facility", "maximum": 2242.16, "minimum": 597.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2242.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2242.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0009U", "type": "HCPCS" } ], "description": "Onc brst ca erbb2 amp/nonamp", "standard_charges": [ { "billing_class": "facility", "maximum": 401.25, "minimum": 107.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 107.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 401.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 401.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0010U", "type": "HCPCS" } ], "description": "Nfct ds strn typ whl gen seq", "standard_charges": [ { "billing_class": "facility", "maximum": 1602.23, "minimum": 427.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 427.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1602.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1602.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0011M", "type": "HCPCS" } ], "description": "Onc prst8 ca mrna 12 gen alg", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0011U", "type": "HCPCS" } ], "description": "Rx mntr lc-ms/ms oral fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 429.11, "minimum": 114.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 429.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 429.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0012M", "type": "HCPCS" } ], "description": "Onc mrna 5 gen rsk urthl ca", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0013M", "type": "HCPCS" } ], "description": "Onc mrna 5 gen recr urthl ca", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0015M", "type": "HCPCS" } ], "description": "Adrnl cortcl tum bchm asy 25", "standard_charges": [ { "billing_class": "facility", "maximum": 4895.14, "minimum": 1305.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1305.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4895.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4895.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0016M", "type": "HCPCS" } ], "description": "Onc bladder mrna 209 gen alg", "standard_charges": [ { "billing_class": "facility", "maximum": 13086.11, "minimum": 3489.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3489.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13086.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13086.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0016U", "type": "HCPCS" } ], "description": "Onc hmtlmf neo rna bcr/abl1", "standard_charges": [ { "billing_class": "facility", "maximum": 614.85, "minimum": 163.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 163.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 614.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 614.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0017M", "type": "HCPCS" } ], "description": "Onc dlbcl mrna 20 genes alg", "standard_charges": [ { "billing_class": "facility", "maximum": 9413.29, "minimum": 2510.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2510.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9413.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9413.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0017U", "type": "HCPCS" } ], "description": "Onc hmtlmf neo jak2 mut dna", "standard_charges": [ { "billing_class": "facility", "maximum": 343.73, "minimum": 91.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 343.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 343.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0018M", "type": "HCPCS" } ], "description": "Trnsplj rnl meas cd154+cll", "standard_charges": [ { "billing_class": "facility", "maximum": 2402.74, "minimum": 640.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 640.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2402.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2402.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0018U", "type": "HCPCS" } ], "description": "Onc thyr 10 microrna seq alg", "standard_charges": [ { "billing_class": "facility", "maximum": 11257.84, "minimum": 3002.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3002.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11257.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11257.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0019U", "type": "HCPCS" } ], "description": "Onc rna tiss predict alg", "standard_charges": [ { "billing_class": "facility", "maximum": 13781.25, "minimum": 3675.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3675.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13781.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13781.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0021U", "type": "HCPCS" } ], "description": "Onc prst8 detcj 8 autoantb", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0022U", "type": "HCPCS" } ], "description": "Trgt gen seq dna&rna 23 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 7312.5, "minimum": 1950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7312.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7312.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0023U", "type": "HCPCS" } ], "description": "Onc aml dna detcj/nondetcj", "standard_charges": [ { "billing_class": "facility", "maximum": 931.91, "minimum": 248.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 248.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 931.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 931.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0024U", "type": "HCPCS" } ], "description": "Glyca nuc mr spectrsc quan", "standard_charges": [ { "billing_class": "facility", "maximum": 128.21, "minimum": 34.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 128.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 128.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0025U", "type": "HCPCS" } ], "description": "Tenofovir liq chrom ur quan", "standard_charges": [ { "billing_class": "facility", "maximum": 321.64, "minimum": 114.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 321.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 321.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0026U", "type": "HCPCS" } ], "description": "Onc thyr dna&mrna 112 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 13500.0, "minimum": 3600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0027U", "type": "HCPCS" } ], "description": "Jak2 gene trgt seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 457.16, "minimum": 121.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 121.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 457.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 457.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0029U", "type": "HCPCS" } ], "description": "Rx metab advrs trgt seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2783.51, "minimum": 742.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 742.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2783.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2783.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0030U", "type": "HCPCS" } ], "description": "Rx metab warf trgt seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 502.99, "minimum": 134.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 134.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 502.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 502.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0031U", "type": "HCPCS" } ], "description": "Cyp1a2 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0032U", "type": "HCPCS" } ], "description": "Comt gene", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0033U", "type": "HCPCS" } ], "description": "Htr2a htr2c genes", "standard_charges": [ { "billing_class": "facility", "maximum": 1311.08, "minimum": 1311.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1311.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1311.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0034U", "type": "HCPCS" } ], "description": "Tpmt nudt15 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 1748.14, "minimum": 466.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 466.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1748.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1748.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0035U", "type": "HCPCS" } ], "description": "Neuro csf prion prtn qual", "standard_charges": [ { "billing_class": "facility", "maximum": 2028.71, "minimum": 540.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 540.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2028.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2028.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0036U", "type": "HCPCS" } ], "description": "Xome tum & nml spec seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 17925.0, "minimum": 4780.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4780.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17925.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17925.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0037U", "type": "HCPCS" } ], "description": "Trgt gen seq dna 324 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 13125.0, "minimum": 3500.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13125.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13125.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0038U", "type": "HCPCS" } ], "description": "Vitamin d srm microsamp quan", "standard_charges": [ { "billing_class": "facility", "maximum": 111.0, "minimum": 29.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0039U", "type": "HCPCS" } ], "description": "Dna antb 2strand hi avidity", "standard_charges": [ { "billing_class": "facility", "maximum": 51.53, "minimum": 13.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0040U", "type": "HCPCS" } ], "description": "Bcr/abl1 gene major bp quan", "standard_charges": [ { "billing_class": "facility", "maximum": 1537.13, "minimum": 409.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 409.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1537.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1537.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0041U", "type": "HCPCS" } ], "description": "B brgdrferi antb 5 prtn igm", "standard_charges": [ { "billing_class": "facility", "maximum": 64.54, "minimum": 17.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0042U", "type": "HCPCS" } ], "description": "B brgdrferi antb 12 prtn igg", "standard_charges": [ { "billing_class": "facility", "maximum": 64.54, "minimum": 17.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0043U", "type": "HCPCS" } ], "description": "Tbrf b grp antb 4 prtn igm", "standard_charges": [ { "billing_class": "facility", "maximum": 55.73, "minimum": 14.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0044U", "type": "HCPCS" } ], "description": "Tbrf b grp antb 4 prtn igg", "standard_charges": [ { "billing_class": "facility", "maximum": 55.73, "minimum": 14.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0045U", "type": "HCPCS" } ], "description": "Onc brst dux carc is 12 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0046U", "type": "HCPCS" } ], "description": "Flt3 gene itd variants quan", "standard_charges": [ { "billing_class": "facility", "maximum": 1527.86, "minimum": 407.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 407.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1527.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1527.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0047U", "type": "HCPCS" } ], "description": "Onc prst8 mrna 17 gene alg", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0048U", "type": "HCPCS" } ], "description": "Onc sld org neo dna 468 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0049U", "type": "HCPCS" } ], "description": "Npm1 gene analysis quan", "standard_charges": [ { "billing_class": "facility", "maximum": 1527.86, "minimum": 407.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 407.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1527.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1527.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0050U", "type": "HCPCS" } ], "description": "Trgt gen seq dna 194 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 10937.25, "minimum": 2916.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2916.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10937.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10937.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0051U", "type": "HCPCS" } ], "description": "Rx mntr lc-ms/ms ur 31 pnl", "standard_charges": [ { "billing_class": "facility", "maximum": 726.41, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 726.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 726.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0052U", "type": "HCPCS" } ], "description": "Lpoprtn bld w/5 maj classes", "standard_charges": [ { "billing_class": "facility", "maximum": 126.98, "minimum": 33.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 126.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 126.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0054U", "type": "HCPCS" } ], "description": "Rx mntr 14+ drugs & sbsts", "standard_charges": [ { "billing_class": "facility", "maximum": 558.6, "minimum": 198.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 198.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 558.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 558.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0055U", "type": "HCPCS" } ], "description": "Card hrt trnspl 96 dna seq", "standard_charges": [ { "billing_class": "facility", "maximum": 12150.0, "minimum": 3240.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3240.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12150.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12150.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0058U", "type": "HCPCS" } ], "description": "Onc merkel cll carc srm quan", "standard_charges": [ { "billing_class": "facility", "maximum": 1211.1, "minimum": 322.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 322.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1211.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1211.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0059U", "type": "HCPCS" } ], "description": "Onc merkel cll carc srm +/-", "standard_charges": [ { "billing_class": "facility", "maximum": 1211.1, "minimum": 322.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 322.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1211.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1211.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0060U", "type": "HCPCS" } ], "description": "Twn zyg gen seq alys chrms2", "standard_charges": [ { "billing_class": "facility", "maximum": 2846.44, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2846.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2846.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0061U", "type": "HCPCS" } ], "description": "Tc meas 5 bmrk sfdi m-s alys", "standard_charges": [ { "billing_class": "facility", "maximum": 94.13, "minimum": 25.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0062U", "type": "HCPCS" } ], "description": "Ai sle igg&igm alys 80 bmrk", "standard_charges": [ { "billing_class": "facility", "maximum": 1427.7, "minimum": 380.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 380.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1427.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1427.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0063U", "type": "HCPCS" } ], "description": "Neuro autism 32 amines alg", "standard_charges": [ { "billing_class": "facility", "maximum": 2812.5, "minimum": 750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2812.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2812.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0064U", "type": "HCPCS" } ], "description": "Antb tp total&rpr ia qual", "standard_charges": [ { "billing_class": "facility", "maximum": 117.49, "minimum": 31.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 117.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0065U", "type": "HCPCS" } ], "description": "Syfls tst nontreponemal antb", "standard_charges": [ { "billing_class": "facility", "maximum": 67.84, "minimum": 18.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0067U", "type": "HCPCS" } ], "description": "Onc brst imhchem prfl 4 bmrk", "standard_charges": [ { "billing_class": "facility", "maximum": 7113.75, "minimum": 1897.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1897.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7113.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7113.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0068U", "type": "HCPCS" } ], "description": "Candida species pnl amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0069U", "type": "HCPCS" } ], "description": "Onc clrct microrna mir-31-3p", "standard_charges": [ { "billing_class": "facility", "maximum": 1425.0, "minimum": 380.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 380.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1425.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1425.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0070U", "type": "HCPCS" } ], "description": "Cyp2d6 gen com&slct rar vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 2536.39, "minimum": 676.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 676.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2536.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2536.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0071U", "type": "HCPCS" } ], "description": "Cyp2d6 full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2250.0, "minimum": 600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2250.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2250.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0072U", "type": "HCPCS" } ], "description": "Cyp2d6 gen cyp2d6-2d7 hybrid", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.91, "minimum": 450.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 450.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0073U", "type": "HCPCS" } ], "description": "Cyp2d6 gen cyp2d7-2d6 hybrid", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.91, "minimum": 450.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 450.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0074U", "type": "HCPCS" } ], "description": "Cyp2d6 nonduplicated gene", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.91, "minimum": 450.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 450.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0075U", "type": "HCPCS" } ], "description": "Cyp2d6 5' gene dup/mlt", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.91, "minimum": 450.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 450.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0076U", "type": "HCPCS" } ], "description": "Cyp2d6 3' gene dup/mlt", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.91, "minimum": 450.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 450.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0077U", "type": "HCPCS" } ], "description": "Ig paraprotein qual bld/ur", "standard_charges": [ { "billing_class": "facility", "maximum": 162.86, "minimum": 43.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 162.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 162.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0078U", "type": "HCPCS" } ], "description": "Pain mgt opi use gnotyp pnl", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.91, "minimum": 1690.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0080U", "type": "HCPCS" } ], "description": "Onc lng 5 clin rsk factr alg", "standard_charges": [ { "billing_class": "facility", "maximum": 13200.0, "minimum": 3520.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3520.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13200.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13200.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0082U", "type": "HCPCS" } ], "description": "Rx test def 90+ rx/sbsts ur", "standard_charges": [ { "billing_class": "facility", "maximum": 925.95, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 925.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 925.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0083U", "type": "HCPCS" } ], "description": "Onc rspse chemo cntrst tomog", "standard_charges": [ { "billing_class": "facility", "maximum": 627.56, "minimum": 167.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 627.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 627.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0084U", "type": "HCPCS" } ], "description": "Rbc dna gnotyp 10 bld groups", "standard_charges": [ { "billing_class": "facility", "maximum": 2700.0, "minimum": 720.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 720.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2700.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2700.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0086U", "type": "HCPCS" } ], "description": "Nfct ds bact&fng org id 6+", "standard_charges": [ { "billing_class": "facility", "maximum": 750.0, "minimum": 200.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 200.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 750.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0087U", "type": "HCPCS" } ], "description": "Crd hrt trnspl mrna 1283 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 11847.83, "minimum": 3159.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3159.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11847.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11847.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0088U", "type": "HCPCS" } ], "description": "Trnsplj kdn algrft rej 1494", "standard_charges": [ { "billing_class": "facility", "maximum": 11847.83, "minimum": 3159.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3159.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11847.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11847.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0089U", "type": "HCPCS" } ], "description": "Onc mlnma prame & linc00518", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0090U", "type": "HCPCS" } ], "description": "Onc cutan mlnma mrna 23 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 6581.25, "minimum": 1950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6581.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6581.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0092U", "type": "HCPCS" } ], "description": "Onc lng 3 prtn bmrk plsm alg", "standard_charges": [ { "billing_class": "facility", "maximum": 9330.0, "minimum": 2488.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2488.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9330.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9330.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0093U", "type": "HCPCS" } ], "description": "Rx mntr 65 com drugs urine", "standard_charges": [ { "billing_class": "facility", "maximum": 233.03, "minimum": 62.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 233.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 233.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0094U", "type": "HCPCS" } ], "description": "Genome rapid sequence alys", "standard_charges": [ { "billing_class": "facility", "maximum": 28433.25, "minimum": 7582.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7582.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28433.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28433.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0095U", "type": "HCPCS" } ], "description": "Inflm ee elisa alys alg", "standard_charges": [ { "billing_class": "facility", "maximum": 2894.93, "minimum": 771.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 771.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2894.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2894.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0096U", "type": "HCPCS" } ], "description": "Hpv hi risk types male urine", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0101U", "type": "HCPCS" } ], "description": "Hered colon ca do 15 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 6539.81, "minimum": 1743.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1743.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6539.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6539.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0102U", "type": "HCPCS" } ], "description": "Hered brst ca rltd do 17 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 4889.81, "minimum": 1303.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1303.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4889.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4889.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0103U", "type": "HCPCS" } ], "description": "Hered ova ca pnl 24 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 6539.81, "minimum": 1743.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1743.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6539.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6539.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0105U", "type": "HCPCS" } ], "description": "Neph ckd mult eclia tum nec", "standard_charges": [ { "billing_class": "facility", "maximum": 3562.5, "minimum": 950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3562.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3562.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0106U", "type": "HCPCS" } ], "description": "Gstr emptg 7 timed brth spec", "standard_charges": [ { "billing_class": "facility", "maximum": 3279.34, "minimum": 874.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3279.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3279.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0107U", "type": "HCPCS" } ], "description": "C diff tox ag detcj ia stool", "standard_charges": [ { "billing_class": "facility", "maximum": 60.0, "minimum": 16.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0108U", "type": "HCPCS" } ], "description": "Gi barrett esoph 9 prtn bmrk", "standard_charges": [ { "billing_class": "facility", "maximum": 18562.5, "minimum": 4950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18562.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18562.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0109U", "type": "HCPCS" } ], "description": "Id aspergillus dna 4 species", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0110U", "type": "HCPCS" } ], "description": "Rx mntr 1+oral onc rx&sbsts", "standard_charges": [ { "billing_class": "facility", "maximum": 101.66, "minimum": 27.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0111U", "type": "HCPCS" } ], "description": "Onc colon ca kras&nras alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2558.59, "minimum": 682.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2558.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2558.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0112U", "type": "HCPCS" } ], "description": "Iadi 16s&18s rrna genes", "standard_charges": [ { "billing_class": "facility", "maximum": 1335.49, "minimum": 356.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 356.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1335.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1335.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0113U", "type": "HCPCS" } ], "description": "Onc prst8 pca3&tmprss2-erg", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0114U", "type": "HCPCS" } ], "description": "Gi barretts esoph vim&ccna1", "standard_charges": [ { "billing_class": "facility", "maximum": 7267.54, "minimum": 1938.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1938.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7267.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7267.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0115U", "type": "HCPCS" } ], "description": "Respir iadna 18 viral&2 bact", "standard_charges": [ { "billing_class": "facility", "maximum": 1032.56, "minimum": 275.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 275.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1032.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1032.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0116U", "type": "HCPCS" } ], "description": "Rx mntr nzm ia 35+oral flu", "standard_charges": [ { "billing_class": "facility", "maximum": 925.95, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 925.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 925.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0117U", "type": "HCPCS" } ], "description": "Pain mgmt 11 endogenous anal", "standard_charges": [ { "billing_class": "facility", "maximum": 3152.44, "minimum": 840.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 840.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3152.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3152.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0118U", "type": "HCPCS" } ], "description": "Trnsplj don-drv cll-fr dna", "standard_charges": [ { "billing_class": "facility", "maximum": 10324.69, "minimum": 2753.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2753.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10324.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10324.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0119U", "type": "HCPCS" } ], "description": "Crd ceramides liq chrom plsm", "standard_charges": [ { "billing_class": "facility", "maximum": 314.1, "minimum": 83.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 314.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 314.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0120U", "type": "HCPCS" } ], "description": "Onc b cll lymphm mrna 58 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 9413.29, "minimum": 2510.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2510.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9413.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9413.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0121U", "type": "HCPCS" } ], "description": "Sc dis vcam-1 whole blood", "standard_charges": [ { "billing_class": "facility", "maximum": 1909.5, "minimum": 509.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 509.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1909.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1909.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0122U", "type": "HCPCS" } ], "description": "Sc dis p-selectin whl blood", "standard_charges": [ { "billing_class": "facility", "maximum": 1973.36, "minimum": 526.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1973.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1973.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0123U", "type": "HCPCS" } ], "description": "Mchnl fragility rbc prflg", "standard_charges": [ { "billing_class": "facility", "maximum": 1341.11, "minimum": 357.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 357.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1341.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1341.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0129U", "type": "HCPCS" } ], "description": "Hered brst ca rltd do panel", "standard_charges": [ { "billing_class": "facility", "maximum": 4889.81, "minimum": 1303.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1303.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4889.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4889.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0130U", "type": "HCPCS" } ], "description": "Hered colon ca do mrna pnl", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 584.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0131U", "type": "HCPCS" } ], "description": "Hered brst ca rltd do pnl 13", "standard_charges": [ { "billing_class": "facility", "maximum": 2662.5, "minimum": 2662.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2662.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2662.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0132U", "type": "HCPCS" } ], "description": "Hered ova ca rltd do pnl 17", "standard_charges": [ { "billing_class": "facility", "maximum": 2781.15, "minimum": 2781.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2781.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2781.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0133U", "type": "HCPCS" } ], "description": "Hered prst8 ca rltd do 11", "standard_charges": [ { "billing_class": "facility", "maximum": 2588.59, "minimum": 690.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 690.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2588.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2588.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0134U", "type": "HCPCS" } ], "description": "Hered pan ca mrna pnl 18 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2806.46, "minimum": 748.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 748.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2806.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2806.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0135U", "type": "HCPCS" } ], "description": "Hered gyn ca mrna pnl 12 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2627.1, "minimum": 2627.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2627.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2627.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0136U", "type": "HCPCS" } ], "description": "Atm mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1527.86, "minimum": 407.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 407.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1527.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1527.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0137U", "type": "HCPCS" } ], "description": "Palb2 mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0138U", "type": "HCPCS" } ], "description": "Brca1 brca2 mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1756.24, "minimum": 468.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 468.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1756.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1756.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0140U", "type": "HCPCS" } ], "description": "Nfct ds fungi dna 15 trgt", "standard_charges": [ { "billing_class": "facility", "maximum": 587.81, "minimum": 156.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 587.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 587.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0141U", "type": "HCPCS" } ], "description": "Nfct ds bact&fng gram pos", "standard_charges": [ { "billing_class": "facility", "maximum": 587.81, "minimum": 156.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 587.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 587.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0142U", "type": "HCPCS" } ], "description": "Nfct ds bact&fng gram neg", "standard_charges": [ { "billing_class": "facility", "maximum": 587.81, "minimum": 156.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 587.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 587.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0152U", "type": "HCPCS" } ], "description": "Nfct bct fng prst dna >1000", "standard_charges": [ { "billing_class": "facility", "maximum": 7973.25, "minimum": 2126.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2126.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7973.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7973.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0153U", "type": "HCPCS" } ], "description": "Onc breast mrna 101 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 11847.83, "minimum": 3159.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3159.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11847.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11847.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0154U", "type": "HCPCS" } ], "description": "Fgfr3 gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1808.03, "minimum": 482.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 482.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1808.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1808.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0155U", "type": "HCPCS" } ], "description": "Pik3ca gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0156U", "type": "HCPCS" } ], "description": "Copy number sequence alys", "standard_charges": [ { "billing_class": "facility", "maximum": 6525.0, "minimum": 1740.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1740.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6525.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6525.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0157U", "type": "HCPCS" } ], "description": "Apc mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0158U", "type": "HCPCS" } ], "description": "Mlh1 mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0159U", "type": "HCPCS" } ], "description": "Msh2 mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0160U", "type": "HCPCS" } ], "description": "Msh6 mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0161U", "type": "HCPCS" } ], "description": "Pms2 mrna seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0162U", "type": "HCPCS" } ], "description": "Hered colon ca trgt mrna pnl", "standard_charges": [ { "billing_class": "facility", "maximum": 1824.53, "minimum": 486.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 486.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1824.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1824.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0163U", "type": "HCPCS" } ], "description": "Onc clrct scr 3 prtn alg", "standard_charges": [ { "billing_class": "facility", "maximum": 1465.31, "minimum": 1465.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1465.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1465.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0164U", "type": "HCPCS" } ], "description": "Gi ibs ia anti-cdtb&vinculin", "standard_charges": [ { "billing_class": "facility", "maximum": 420.08, "minimum": 112.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 112.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 420.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 420.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0165U", "type": "HCPCS" } ], "description": "Peanut allg spec asmt 64 epi", "standard_charges": [ { "billing_class": "facility", "maximum": 1739.1, "minimum": 463.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 463.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1739.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1739.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0166U", "type": "HCPCS" } ], "description": "Liver ds 10 biochem asy srm", "standard_charges": [ { "billing_class": "facility", "maximum": 1887.75, "minimum": 503.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 503.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1887.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1887.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0167U", "type": "HCPCS" } ], "description": "Chornc gonadotropin hcg ia", "standard_charges": [ { "billing_class": "facility", "maximum": 28.2, "minimum": 28.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0169U", "type": "HCPCS" } ], "description": "Nudt15&tpmt gene com vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 1748.14, "minimum": 466.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 466.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1748.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1748.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0170U", "type": "HCPCS" } ], "description": "Neuro asd rna next gen seq", "standard_charges": [ { "billing_class": "facility", "maximum": 6581.25, "minimum": 1950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6581.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6581.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0171U", "type": "HCPCS" } ], "description": "Trgt gen seq alys pnl dna 23", "standard_charges": [ { "billing_class": "facility", "maximum": 5696.48, "minimum": 1519.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1519.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5696.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5696.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0172U", "type": "HCPCS" } ], "description": "Onc sld tum alys brca1 brca2", "standard_charges": [ { "billing_class": "facility", "maximum": 11362.5, "minimum": 3030.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3030.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11362.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11362.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0173U", "type": "HCPCS" } ], "description": "Psyc gen alys panel 14 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 1748.14, "minimum": 466.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 466.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1748.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1748.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0174U", "type": "HCPCS" } ], "description": "Onc solid tumor 30 prtn trgt", "standard_charges": [ { "billing_class": "facility", "maximum": 4895.14, "minimum": 1305.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1305.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4895.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4895.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0175U", "type": "HCPCS" } ], "description": "Psyc gen alys panel 15 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 5010.34, "minimum": 1336.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1336.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5010.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5010.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0176U", "type": "HCPCS" } ], "description": "Cdtb&vinculin igg antb ia", "standard_charges": [ { "billing_class": "facility", "maximum": 240.71, "minimum": 64.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 240.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 240.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0177U", "type": "HCPCS" } ], "description": "Onc brst ca dna pik3ca 11", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0178U", "type": "HCPCS" } ], "description": "Peanut allg asmt epi clin rx", "standard_charges": [ { "billing_class": "facility", "maximum": 1724.48, "minimum": 459.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 459.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1724.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1724.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0179U", "type": "HCPCS" } ], "description": "Onc nonsm cll lng ca alys 23", "standard_charges": [ { "billing_class": "facility", "maximum": 7287.04, "minimum": 1943.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1943.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7287.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7287.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0180U", "type": "HCPCS" } ], "description": "Abo gnotyp abo 7 exons", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0181U", "type": "HCPCS" } ], "description": "Co gnotyp aqp1 exon 1", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0182U", "type": "HCPCS" } ], "description": "Crom gnotyp cd55 exons 1-10", "standard_charges": [ { "billing_class": "facility", "maximum": 1130.06, "minimum": 301.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 301.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1130.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1130.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0183U", "type": "HCPCS" } ], "description": "Di gnotyp slc4a1 exon 19", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0184U", "type": "HCPCS" } ], "description": "Do gnotyp art4 exon 2", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0185U", "type": "HCPCS" } ], "description": "Fut1 gnotyp fut1 exon 4", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0186U", "type": "HCPCS" } ], "description": "Fut2 gnotyp fut2 exon 2", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0187U", "type": "HCPCS" } ], "description": "Fy gnotyp ackr1 exons 1-2", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0188U", "type": "HCPCS" } ], "description": "Ge gnotyp gypc exons 1-4", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0189U", "type": "HCPCS" } ], "description": "Gypa gnotyp ntrns 1 5 exon 2", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0190U", "type": "HCPCS" } ], "description": "Gypb gnotyp ntrns 1 5 seux 3", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0191U", "type": "HCPCS" } ], "description": "In gnotyp cd44 exons 2 3 6", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0192U", "type": "HCPCS" } ], "description": "Jk gnotyp slc14a1 exon 9", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0193U", "type": "HCPCS" } ], "description": "Jr gnotyp abcg2 exons 2-26", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0194U", "type": "HCPCS" } ], "description": "Kel gnotyp kel exon 8", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0195U", "type": "HCPCS" } ], "description": "Klf1 targeted sequencing", "standard_charges": [ { "billing_class": "facility", "maximum": 1407.19, "minimum": 375.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 375.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1407.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1407.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0196U", "type": "HCPCS" } ], "description": "Lu gnotyp bcam exon 3", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0197U", "type": "HCPCS" } ], "description": "Lw gnotyp icam4 exon 1", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0198U", "type": "HCPCS" } ], "description": "Rhd&rhce gntyp rhd1-10&rhce5", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0199U", "type": "HCPCS" } ], "description": "Sc gnotyp ermap exons 4 12", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0200U", "type": "HCPCS" } ], "description": "Xk gnotyp xk exons 1-3", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0201U", "type": "HCPCS" } ], "description": "Yt gnotyp ache exon 2", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0202U", "type": "HCPCS" } ], "description": "Nfct ds 22 trgt sars-cov-2", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0203U", "type": "HCPCS" } ], "description": "Ai ibd mrna xprsn prfl 17", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0204U", "type": "HCPCS" } ], "description": "Onc thyr mrna xprsn alys 593", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 10948.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0205U", "type": "HCPCS" } ], "description": "Oph amd alys 3 gene variants", "standard_charges": [ { "billing_class": "facility", "maximum": 176.25, "minimum": 47.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 176.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 176.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0206U", "type": "HCPCS" } ], "description": "Neuro alzheimer cell aggregj", "standard_charges": [ { "billing_class": "facility", "maximum": 8307.75, "minimum": 2215.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2215.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8307.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8307.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0207U", "type": "HCPCS" } ], "description": "Neuro alzheimer quan imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 1917.0, "minimum": 1917.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1917.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1917.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0209U", "type": "HCPCS" } ], "description": "Cytog const alys interrog", "standard_charges": [ { "billing_class": "facility", "maximum": 2951.81, "minimum": 787.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 787.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2951.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2951.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0210U", "type": "HCPCS" } ], "description": "Syphilis tst antb ia quan", "standard_charges": [ { "billing_class": "facility", "maximum": 69.86, "minimum": 18.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0211U", "type": "HCPCS" } ], "description": "Onc pan-tum dna&rna gnrj seq", "standard_charges": [ { "billing_class": "facility", "maximum": 31706.25, "minimum": 8455.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8455.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31706.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31706.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0212U", "type": "HCPCS" } ], "description": "Rare ds gen dna alys proband", "standard_charges": [ { "billing_class": "facility", "maximum": 20532.0, "minimum": 5475.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5475.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20532.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20532.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0213U", "type": "HCPCS" } ], "description": "Rare ds gen dna alys ea comp", "standard_charges": [ { "billing_class": "facility", "maximum": 10162.31, "minimum": 2709.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2709.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10162.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10162.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0214U", "type": "HCPCS" } ], "description": "Rare ds xom dna alys proband", "standard_charges": [ { "billing_class": "facility", "maximum": 19592.25, "minimum": 5224.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5224.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19592.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19592.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0215U", "type": "HCPCS" } ], "description": "Rare ds xom dna alys ea comp", "standard_charges": [ { "billing_class": "facility", "maximum": 9654.94, "minimum": 2574.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2574.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9654.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9654.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0216U", "type": "HCPCS" } ], "description": "Neuro inh ataxia dna 12 com", "standard_charges": [ { "billing_class": "facility", "maximum": 5763.83, "minimum": 1537.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1537.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5763.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5763.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0217U", "type": "HCPCS" } ], "description": "Neuro inh ataxia dna 51 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 8243.81, "minimum": 2198.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2198.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8243.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8243.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0218U", "type": "HCPCS" } ], "description": "Neuro musc dys dmd seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 8546.25, "minimum": 2279.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2279.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8546.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8546.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0219U", "type": "HCPCS" } ], "description": "Nfct agt hiv gnrj seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2718.75, "minimum": 725.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 725.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2718.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2718.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0220U", "type": "HCPCS" } ], "description": "Onc brst ca ai assmt 12 feat", "standard_charges": [ { "billing_class": "facility", "maximum": 2648.44, "minimum": 706.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2648.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2648.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0221U", "type": "HCPCS" } ], "description": "Abo gnotyp next gnrj seq abo", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0222U", "type": "HCPCS" } ], "description": "Rhd&rhce gntyp next gnrj seq", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0223U", "type": "HCPCS" } ], "description": "Nfct ds 22 trgt sars-cov-2", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0224U", "type": "HCPCS" } ], "description": "Antibody sars-cov-2 titer(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 192.86, "minimum": 51.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0225U", "type": "HCPCS" } ], "description": "Nfct ds dna&rna 21 sarscov2", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0226U", "type": "HCPCS" } ], "description": "Svnt sarscov2 elisa plsm srm", "standard_charges": [ { "billing_class": "facility", "maximum": 158.55, "minimum": 42.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 158.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 158.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0227U", "type": "HCPCS" } ], "description": "Rx asy prsmv 30+rx/metablt", "standard_charges": [ { "billing_class": "facility", "maximum": 233.03, "minimum": 62.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 233.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 233.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0228U", "type": "HCPCS" } ], "description": "Onc prst8 ma molec prfl alg", "standard_charges": [ { "billing_class": "facility", "maximum": 648.86, "minimum": 173.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 173.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 648.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 648.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0229U", "type": "HCPCS" } ], "description": "Bcat1 promoter mthyltn alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1440.0, "minimum": 384.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 384.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1440.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1440.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0230U", "type": "HCPCS" } ], "description": "Ar full sequence analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1130.06, "minimum": 301.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 301.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1130.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1130.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0231U", "type": "HCPCS" } ], "description": "Cacna1a full gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 3173.51, "minimum": 846.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 846.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3173.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3173.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0232U", "type": "HCPCS" } ], "description": "Cstb full gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0233U", "type": "HCPCS" } ], "description": "Fxn gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0234U", "type": "HCPCS" } ], "description": "Mecp2 full gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1979.51, "minimum": 527.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 527.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1979.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1979.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0235U", "type": "HCPCS" } ], "description": "Pten full gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 2250.0, "minimum": 600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2250.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2250.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0236U", "type": "HCPCS" } ], "description": "Smn1&smn2 full gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 2260.13, "minimum": 602.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 602.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2260.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2260.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0237U", "type": "HCPCS" } ], "description": "Car ion chnlpthy gen seq pnl", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 584.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0238U", "type": "HCPCS" } ], "description": "Onc lnch syn gen dna seq aly", "standard_charges": [ { "billing_class": "facility", "maximum": 2193.38, "minimum": 584.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2193.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2193.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0239U", "type": "HCPCS" } ], "description": "Trgt gen seq alys pnl 311+", "standard_charges": [ { "billing_class": "facility", "maximum": 13125.0, "minimum": 3500.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13125.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13125.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0240U", "type": "HCPCS" } ], "description": "Nfct ds vir resp rna 3 trgt", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 534.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0241U", "type": "HCPCS" } ], "description": "Nfct ds vir resp rna 4 trgt", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 534.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0242U", "type": "HCPCS" } ], "description": "Trgt gen seq alys pnl 55-74", "standard_charges": [ { "billing_class": "facility", "maximum": 18750.0, "minimum": 5000.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5000.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18750.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0243U", "type": "HCPCS" } ], "description": "Ob pe biochem assay pgf alg", "standard_charges": [ { "billing_class": "facility", "maximum": 241.54, "minimum": 64.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0244U", "type": "HCPCS" } ], "description": "Onc solid orgn dna 257 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 13125.0, "minimum": 3500.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13125.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13125.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0245U", "type": "HCPCS" } ], "description": "Onc thyr mut alys 10 gen&37", "standard_charges": [ { "billing_class": "facility", "maximum": 4747.76, "minimum": 1266.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1266.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4747.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4747.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0246U", "type": "HCPCS" } ], "description": "Rbc dna gnotyp 16 bld groups", "standard_charges": [ { "billing_class": "facility", "maximum": 2700.0, "minimum": 720.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 720.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2700.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2700.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0247U", "type": "HCPCS" } ], "description": "Ob prtrm brth ibp4 shbg meas", "standard_charges": [ { "billing_class": "facility", "maximum": 2812.5, "minimum": 750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2812.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2812.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0248U", "type": "HCPCS" } ], "description": "Onc brn sphrd cll 12 rx pnl", "standard_charges": [ { "billing_class": "facility", "maximum": 11376.98, "minimum": 3033.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3033.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11376.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11376.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0249U", "type": "HCPCS" } ], "description": "Onc brst alys 32 phsprtn alg", "standard_charges": [ { "billing_class": "facility", "maximum": 8321.74, "minimum": 2219.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2219.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8321.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8321.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0250U", "type": "HCPCS" } ], "description": "Onc sld org neo dna 505 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0251U", "type": "HCPCS" } ], "description": "Hepcidin-25 elisa serum/plsm", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0252U", "type": "HCPCS" } ], "description": "Ftl aneuploidy str alys dna", "standard_charges": [ { "billing_class": "facility", "maximum": 2846.44, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2846.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2846.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0253U", "type": "HCPCS" } ], "description": "Rprdtve med rna gen prfl 238", "standard_charges": [ { "billing_class": "facility", "maximum": 11847.83, "minimum": 3159.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3159.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11847.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11847.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0254U", "type": "HCPCS" } ], "description": "Reprdtve med alys 24 chrmsm", "standard_charges": [ { "billing_class": "facility", "maximum": 2846.44, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2846.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2846.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0255U", "type": "HCPCS" } ], "description": "Andrology infertility assmt", "standard_charges": [ { "billing_class": "facility", "maximum": 118.5, "minimum": 31.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 118.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 118.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0256U", "type": "HCPCS" } ], "description": "Tma/tmao prfl ms/ms ur alg", "standard_charges": [ { "billing_class": "facility", "maximum": 599.81, "minimum": 159.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 159.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 599.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 599.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0257U", "type": "HCPCS" } ], "description": "Vlcad leuk nzm actv whl bld", "standard_charges": [ { "billing_class": "facility", "maximum": 2671.76, "minimum": 712.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2671.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2671.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0258U", "type": "HCPCS" } ], "description": "Ai psor mrna 50-100 gen alg", "standard_charges": [ { "billing_class": "facility", "maximum": 13781.25, "minimum": 3675.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3675.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13781.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13781.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0259U", "type": "HCPCS" } ], "description": "Neph ckd nuc mrs meas gfr", "standard_charges": [ { "billing_class": "facility", "maximum": 197.66, "minimum": 52.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 197.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 197.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0260U", "type": "HCPCS" } ], "description": "Rare ds id opt genome mapg", "standard_charges": [ { "billing_class": "facility", "maximum": 4738.24, "minimum": 1263.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1263.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4738.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4738.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0261U", "type": "HCPCS" } ], "description": "Onc clrct ca img alys w/ai", "standard_charges": [ { "billing_class": "facility", "maximum": 18562.5, "minimum": 2513.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2513.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18562.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18562.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0262U", "type": "HCPCS" } ], "description": "Onc sld tum rt-pcr 7 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 12000.0, "minimum": 3200.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3200.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12000.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12000.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0263U", "type": "HCPCS" } ], "description": "Neuro asd meas 16 c metblt", "standard_charges": [ { "billing_class": "facility", "maximum": 2812.5, "minimum": 750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2812.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2812.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0264U", "type": "HCPCS" } ], "description": "Rare ds id opt genome mapg", "standard_charges": [ { "billing_class": "facility", "maximum": 4738.24, "minimum": 1263.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1263.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4738.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4738.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0265U", "type": "HCPCS" } ], "description": "Rar do whl gn&mtcdrl dna als", "standard_charges": [ { "billing_class": "facility", "maximum": 20534.25, "minimum": 5475.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5475.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20534.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20534.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0266U", "type": "HCPCS" } ], "description": "Unxpl cnst hrtbl do gn xprsn", "standard_charges": [ { "billing_class": "facility", "maximum": 12000.0, "minimum": 3200.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3200.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12000.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12000.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0267U", "type": "HCPCS" } ], "description": "Rare do id opt gen mapg&seq", "standard_charges": [ { "billing_class": "facility", "maximum": 25272.49, "minimum": 6739.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6739.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25272.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25272.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0268U", "type": "HCPCS" } ], "description": "Hem ahus gen seq alys 15 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0269U", "type": "HCPCS" } ], "description": "Hem aut dm cgen trmbctpna 14", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0270U", "type": "HCPCS" } ], "description": "Hem cgen coagj do 20 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0271U", "type": "HCPCS" } ], "description": "Hem cgen neutropenia 23 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0272U", "type": "HCPCS" } ], "description": "Hem genetic bld do 51 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0273U", "type": "HCPCS" } ], "description": "Hem gen hyprfibrnlysis 8 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0274U", "type": "HCPCS" } ], "description": "Hem gen pltlt do 43 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0275U", "type": "HCPCS" } ], "description": "Hem heprn nduc trmbctpna srm", "standard_charges": [ { "billing_class": "facility", "maximum": 68.89, "minimum": 18.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 68.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0276U", "type": "HCPCS" } ], "description": "Hem inh thrombocytopenia 23", "standard_charges": [ { "billing_class": "facility", "maximum": 9182.1, "minimum": 2448.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2448.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9182.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9182.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0277U", "type": "HCPCS" } ], "description": "Hem gen pltlt funcj do 31", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0278U", "type": "HCPCS" } ], "description": "Hem gen thrombosis 12 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2280.64, "minimum": 608.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2280.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2280.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0279U", "type": "HCPCS" } ], "description": "Hem vw factor&clgn iii bndg", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0280U", "type": "HCPCS" } ], "description": "Hem vw factor&clgn iv bndg", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0281U", "type": "HCPCS" } ], "description": "Hem vwd propeptide ag lvl", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0282U", "type": "HCPCS" } ], "description": "Rbc dna gntyp 12 bld grp gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2700.0, "minimum": 720.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 720.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2700.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2700.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0283U", "type": "HCPCS" } ], "description": "Vw factor type 2b eval plsm", "standard_charges": [ { "billing_class": "facility", "maximum": 69.0, "minimum": 18.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0284U", "type": "HCPCS" } ], "description": "Vw factor type 2n eval plsm", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0285U", "type": "HCPCS" } ], "description": "Onc rsps radj cll fr dna tox", "standard_charges": [ { "billing_class": "facility", "maximum": 1662.41, "minimum": 443.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 443.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1662.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1662.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0286U", "type": "HCPCS" } ], "description": "Cep72 nudt15&tpmt gene alys", "standard_charges": [ { "billing_class": "facility", "maximum": 502.99, "minimum": 134.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 134.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 502.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 502.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0287U", "type": "HCPCS" } ], "description": "Onc thyr dna&mrna 112 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 13500.0, "minimum": 3600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0288U", "type": "HCPCS" } ], "description": "Onc lung mrna quan pcr 11&3", "standard_charges": [ { "billing_class": "facility", "maximum": 14523.75, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14523.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14523.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0289U", "type": "HCPCS" } ], "description": "Neuro alzheimer mrna 24 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0290U", "type": "HCPCS" } ], "description": "Pain mgmt mrna gen xprsn 36", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0291U", "type": "HCPCS" } ], "description": "Psyc mood do mrna 144 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 6581.25, "minimum": 1755.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1755.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6581.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6581.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0292U", "type": "HCPCS" } ], "description": "Psyc strs do mrna 72 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 6581.25, "minimum": 1755.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1755.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6581.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6581.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0293U", "type": "HCPCS" } ], "description": "Psyc suicidal idea mrna 54", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0294U", "type": "HCPCS" } ], "description": "Lngvty&mrtlty rsk mrna 18gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 2850.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0295U", "type": "HCPCS" } ], "description": "Onc brst dux carc 7 proteins", "standard_charges": [ { "billing_class": "facility", "maximum": 7113.75, "minimum": 5435.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7113.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7113.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0296U", "type": "HCPCS" } ], "description": "Onc orl&/orop ca 20 mlc feat", "standard_charges": [ { "billing_class": "facility", "maximum": 6581.25, "minimum": 1950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6581.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6581.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0297U", "type": "HCPCS" } ], "description": "Onc pan tum whl gen seq dna", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0298U", "type": "HCPCS" } ], "description": "Onc pan tum whl trns seq rna", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0299U", "type": "HCPCS" } ], "description": "Onc pan tum whl gen opt mapg", "standard_charges": [ { "billing_class": "facility", "maximum": 6987.08, "minimum": 1863.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1863.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6987.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6987.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0300U", "type": "HCPCS" } ], "description": "Onc pan tum whl gen seq&opt", "standard_charges": [ { "billing_class": "facility", "maximum": 15686.74, "minimum": 4183.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4183.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15686.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15686.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0301U", "type": "HCPCS" } ], "description": "Iadna bartonella ddpcr", "standard_charges": [ { "billing_class": "facility", "maximum": 985.2, "minimum": 262.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 262.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 985.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 985.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0302U", "type": "HCPCS" } ], "description": "Iadna brtnla ddpcr flwg liq", "standard_charges": [ { "billing_class": "facility", "maximum": 1355.14, "minimum": 361.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1355.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1355.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0303U", "type": "HCPCS" } ], "description": "Hem rbc ads whl bld hypoxic", "standard_charges": [ { "billing_class": "facility", "maximum": 8256.08, "minimum": 2201.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2201.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8256.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8256.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0304U", "type": "HCPCS" } ], "description": "Hem rbc ads whl bld normoxic", "standard_charges": [ { "billing_class": "facility", "maximum": 7784.25, "minimum": 2075.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2075.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7784.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7784.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0305U", "type": "HCPCS" } ], "description": "Hem rbc fnclty&dfrm shr strs", "standard_charges": [ { "billing_class": "facility", "maximum": 2484.68, "minimum": 662.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 662.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2484.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2484.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0306U", "type": "HCPCS" } ], "description": "Onc mrd nxt-gnrj alys 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 14544.19, "minimum": 3878.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3878.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14544.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14544.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0307U", "type": "HCPCS" } ], "description": "Onc mrd nxt-gnrj alys sbsq", "standard_charges": [ { "billing_class": "facility", "maximum": 2979.34, "minimum": 794.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 794.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2979.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2979.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0308U", "type": "HCPCS" } ], "description": "Crd cad alys 3 prtn plsm alg", "standard_charges": [ { "billing_class": "facility", "maximum": 1465.31, "minimum": 390.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 390.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1465.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1465.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0309U", "type": "HCPCS" } ], "description": "Crd cv ds aly 4 prtn plm alg", "standard_charges": [ { "billing_class": "facility", "maximum": 1465.31, "minimum": 390.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 390.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1465.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1465.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0310U", "type": "HCPCS" } ], "description": "Ped vsclts kd alys 3 bmrks", "standard_charges": [ { "billing_class": "facility", "maximum": 1465.31, "minimum": 390.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 390.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1465.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1465.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0311U", "type": "HCPCS" } ], "description": "Nfct ds bct quan antmcrb sc", "standard_charges": [ { "billing_class": "facility", "maximum": 30.3, "minimum": 8.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0312U", "type": "HCPCS" } ], "description": "Ai ds sle alys 8 igg autoant", "standard_charges": [ { "billing_class": "facility", "maximum": 3152.44, "minimum": 840.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 840.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3152.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3152.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0313U", "type": "HCPCS" } ], "description": "Onc pncrs dna&mrna seq 74", "standard_charges": [ { "billing_class": "facility", "maximum": 13500.0, "minimum": 3600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0314U", "type": "HCPCS" } ], "description": "Onc cutan mlnma mrna 35 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 7312.5, "minimum": 1950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7312.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7312.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0315U", "type": "HCPCS" } ], "description": "Onc cutan sq cll ca mrna 40", "standard_charges": [ { "billing_class": "facility", "maximum": 31875.0, "minimum": 8500.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31875.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31875.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0316U", "type": "HCPCS" } ], "description": "B brgdrferi lyme ds ospa evl", "standard_charges": [ { "billing_class": "facility", "maximum": 69.98, "minimum": 18.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0317U", "type": "HCPCS" } ], "description": "Onc lung ca 4-prb fish assay", "standard_charges": [ { "billing_class": "facility", "maximum": 7612.5, "minimum": 2030.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2030.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7612.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7612.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0318U", "type": "HCPCS" } ], "description": "Ped whl gen mthyltn alys 50+", "standard_charges": [ { "billing_class": "facility", "maximum": 6639.3, "minimum": 1770.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1770.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6639.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6639.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0319U", "type": "HCPCS" } ], "description": "Neph rna pretrnspl perph bld", "standard_charges": [ { "billing_class": "facility", "maximum": 9937.5, "minimum": 2650.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2650.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9937.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9937.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0320U", "type": "HCPCS" } ], "description": "Neph rna psttrnspl perph bld", "standard_charges": [ { "billing_class": "facility", "maximum": 9937.5, "minimum": 2650.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2650.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9937.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9937.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0321U", "type": "HCPCS" } ], "description": "Iadna gu pthgn 20bct&fng org", "standard_charges": [ { "billing_class": "facility", "maximum": 2380.65, "minimum": 634.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 634.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2380.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2380.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0322U", "type": "HCPCS" } ], "description": "Neuro asd meas 14 acyl carn", "standard_charges": [ { "billing_class": "facility", "maximum": 2812.5, "minimum": 750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2812.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2812.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0323U", "type": "HCPCS" } ], "description": "Iadna cns pthgn next gen seq", "standard_charges": [ { "billing_class": "facility", "maximum": 7973.25, "minimum": 2126.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2126.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7973.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7973.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0326U", "type": "HCPCS" } ], "description": "Trgt gen seq alys pnl 83+", "standard_charges": [ { "billing_class": "facility", "maximum": 18750.0, "minimum": 5000.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5000.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18750.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0327U", "type": "HCPCS" } ], "description": "Ftl aneuploidy trsmy dna seq", "standard_charges": [ { "billing_class": "facility", "maximum": 2981.25, "minimum": 795.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 795.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2981.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2981.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0328U", "type": "HCPCS" } ], "description": "Drug assay 120+ rx&metablt", "standard_charges": [ { "billing_class": "facility", "maximum": 429.11, "minimum": 114.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 429.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 429.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0329U", "type": "HCPCS" } ], "description": "Onc neo xome&trns seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 12892.43, "minimum": 3437.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3437.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12892.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12892.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0330U", "type": "HCPCS" } ], "description": "Iadna vag pthgn panel 27 org", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0331U", "type": "HCPCS" } ], "description": "Onc hl neo opt gen mapping", "standard_charges": [ { "billing_class": "facility", "maximum": 6987.08, "minimum": 1863.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1863.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6987.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6987.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0332U", "type": "HCPCS" } ], "description": "Onc pan tum gen prflg 8 dna", "standard_charges": [ { "billing_class": "facility", "maximum": 4282.73, "minimum": 1142.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1142.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4282.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4282.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0333U", "type": "HCPCS" } ], "description": "Onc lvr surveilanc hcc cfdna", "standard_charges": [ { "billing_class": "facility", "maximum": 2483.7, "minimum": 662.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 662.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2483.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2483.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0334U", "type": "HCPCS" } ], "description": "Onc sld orgn tgsa dna 84/+", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 3500.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0335U", "type": "HCPCS" } ], "description": "Rare ds whl gen seq fetal", "standard_charges": [ { "billing_class": "facility", "maximum": 19592.25, "minimum": 5224.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5224.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19592.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19592.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0336U", "type": "HCPCS" } ], "description": "Rare ds whl gen seq bld/slv", "standard_charges": [ { "billing_class": "facility", "maximum": 9654.94, "minimum": 2574.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2574.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9654.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9654.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0337U", "type": "HCPCS" } ], "description": "Onc plsm cell do&myeloma id", "standard_charges": [ { "billing_class": "facility", "maximum": 9131.25, "minimum": 2435.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2435.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9131.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9131.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0338U", "type": "HCPCS" } ], "description": "Onc sld tum crcg tum cl slct", "standard_charges": [ { "billing_class": "facility", "maximum": 9131.25, "minimum": 2435.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2435.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9131.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9131.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0339U", "type": "HCPCS" } ], "description": "Onc prst8 mrna hoxc6 & dlx1", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0340U", "type": "HCPCS" } ], "description": "Onc pan ca alys mrd plasma", "standard_charges": [ { "billing_class": "facility", "maximum": 14700.0, "minimum": 3590.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3590.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14700.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14700.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0341U", "type": "HCPCS" } ], "description": "Ftl aneup dna seq cmpr alys", "standard_charges": [ { "billing_class": "facility", "maximum": 7125.75, "minimum": 1900.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1900.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7125.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 7125.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0342U", "type": "HCPCS" } ], "description": "Onc pncrtc ca mult ia eclia", "standard_charges": [ { "billing_class": "facility", "maximum": 3363.75, "minimum": 3363.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3363.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3363.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0343U", "type": "HCPCS" } ], "description": "Onc prst8 xom aly 442 sncrna", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0344U", "type": "HCPCS" } ], "description": "Hep nafld semiq evl 28 lipid", "standard_charges": [ { "billing_class": "facility", "maximum": 2970.64, "minimum": 792.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 792.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2970.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2970.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0345U", "type": "HCPCS" } ], "description": "Psyc genom alys pnl 15 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 5010.34, "minimum": 1336.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1336.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5010.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5010.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0346U", "type": "HCPCS" } ], "description": "Beta amyl a?40&a?42 lc-ms/ms", "standard_charges": [ { "billing_class": "facility", "maximum": 349.73, "minimum": 349.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 349.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 349.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0347U", "type": "HCPCS" } ], "description": "Rx metab/pcx dna 16 gen alys", "standard_charges": [ { "billing_class": "facility", "maximum": 5010.34, "minimum": 1336.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1336.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5010.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5010.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0348U", "type": "HCPCS" } ], "description": "Rx metab/pcx dna 25 gen alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2783.51, "minimum": 742.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 742.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2783.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2783.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0349U", "type": "HCPCS" } ], "description": "Rx metab/pcx dna 27gen rx ia", "standard_charges": [ { "billing_class": "facility", "maximum": 2783.51, "minimum": 742.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 742.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2783.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2783.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0350U", "type": "HCPCS" } ], "description": "Rx metab/pcx dna 27 gen alys", "standard_charges": [ { "billing_class": "facility", "maximum": 5010.34, "minimum": 1336.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1336.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5010.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5010.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0351U", "type": "HCPCS" } ], "description": "Nfct ds bct/viral trail ip10", "standard_charges": [ { "billing_class": "facility", "maximum": 976.88, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 976.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 976.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0352U", "type": "HCPCS" } ], "description": "Nfct ds bv&vaginitis amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 534.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0353U", "type": "HCPCS" } ], "description": "Iadna chlmyd&gonorr amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 263.18, "minimum": 263.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 263.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 263.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0354U", "type": "HCPCS" } ], "description": "Hpv hi rsk qual mrna e6/e7", "standard_charges": [ { "billing_class": "facility", "maximum": 131.59, "minimum": 131.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0355U", "type": "HCPCS" } ], "description": "Apol1 risk variants", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0358U", "type": "HCPCS" } ], "description": "Neuro alys b-amyl 1-42&1-40", "standard_charges": [ { "billing_class": "facility", "maximum": 976.88, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 976.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 976.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0359U", "type": "HCPCS" } ], "description": "Onc prst8 ca alys all psa", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0360U", "type": "HCPCS" } ], "description": "Onc lung elisa 7 autoant alg", "standard_charges": [ { "billing_class": "facility", "maximum": 3152.44, "minimum": 840.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 840.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3152.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3152.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0362U", "type": "HCPCS" } ], "description": "Onc pap thyr ca rna 82&10", "standard_charges": [ { "billing_class": "facility", "maximum": 13500.0, "minimum": 3600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0363U", "type": "HCPCS" } ], "description": "Onc urthl mrna 5 gen alg", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0365U", "type": "HCPCS" } ], "description": "Onc bldr 10 prb bldr ca", "standard_charges": [ { "billing_class": "facility", "maximum": 3363.75, "minimum": 897.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3363.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3363.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0366U", "type": "HCPCS" } ], "description": "Onc bldr 10 prb recr bldr ca", "standard_charges": [ { "billing_class": "facility", "maximum": 3363.75, "minimum": 897.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3363.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3363.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0367U", "type": "HCPCS" } ], "description": "Onc bldr 10 flwg trurl rescj", "standard_charges": [ { "billing_class": "facility", "maximum": 3383.18, "minimum": 902.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 902.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3383.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3383.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0369U", "type": "HCPCS" } ], "description": "Iadna gi pthgn 31 org&21 arg", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 1562.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0370U", "type": "HCPCS" } ], "description": "Iadna surg wnd pthgn 34&21", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 1562.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0371U", "type": "HCPCS" } ], "description": "Iadna gu pthgn semiq dna16&1", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0372U", "type": "HCPCS" } ], "description": "Nfct ds gu pthgn arg detcj", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0373U", "type": "HCPCS" } ], "description": "Iadna rsp tr nfct 17 8 13&16", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 1562.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0374U", "type": "HCPCS" } ], "description": "Iadna gu pthgn 21 org&21arg", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 1562.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0375U", "type": "HCPCS" } ], "description": "Onc ovrn bchm asy 7 prtn alg", "standard_charges": [ { "billing_class": "facility", "maximum": 3363.75, "minimum": 897.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3363.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3363.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0376U", "type": "HCPCS" } ], "description": "Onc prst8 ca img alys 128", "standard_charges": [ { "billing_class": "facility", "maximum": 2648.44, "minimum": 706.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2648.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2648.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0377U", "type": "HCPCS" } ], "description": "Cv ds quan advsrm/plsm lprtn", "standard_charges": [ { "billing_class": "facility", "maximum": 178.43, "minimum": 47.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 178.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 178.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0378U", "type": "HCPCS" } ], "description": "Rfc1 repeat xpnsj vrnt alys", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0380U", "type": "HCPCS" } ], "description": "Rx metb advrs trgt sq aly 20", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 1562.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0384U", "type": "HCPCS" } ], "description": "Neph ckd rsk hi stg kdn ds", "standard_charges": [ { "billing_class": "facility", "maximum": 2812.5, "minimum": 750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2812.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2812.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0385U", "type": "HCPCS" } ], "description": "Neph ckd alg rsk dbtc kdn ds", "standard_charges": [ { "billing_class": "facility", "maximum": 1465.31, "minimum": 390.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 390.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1465.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1465.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0387U", "type": "HCPCS" } ], "description": "Onc mlnma ambra1&amlo", "standard_charges": [ { "billing_class": "facility", "maximum": 3556.88, "minimum": 948.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3556.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3556.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0390U", "type": "HCPCS" } ], "description": "Ob pe kdr eng&rbp4 ia alg", "standard_charges": [ { "billing_class": "facility", "maximum": 241.54, "minimum": 64.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0391U", "type": "HCPCS" } ], "description": "Onc sld tum dna&rna 437 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 13500.0, "minimum": 3600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13500.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0392U", "type": "HCPCS" } ], "description": "Rx metab genrx ia 16 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 5010.34, "minimum": 1336.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1336.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5010.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5010.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0393U", "type": "HCPCS" } ], "description": "Neu prksn msfl ?-syncln prtn", "standard_charges": [ { "billing_class": "facility", "maximum": 2028.71, "minimum": 540.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 540.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2028.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2028.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0394U", "type": "HCPCS" } ], "description": "Pfas 16 pfas compnd lc ms/ms", "standard_charges": [ { "billing_class": "facility", "maximum": 745.28, "minimum": 198.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 198.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 745.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 745.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0402U", "type": "HCPCS" } ], "description": "Nfct agt sti mult amp prb tq", "standard_charges": [ { "billing_class": "facility", "maximum": 534.86, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 534.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 534.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0403U", "type": "HCPCS" } ], "description": "Onc prst8 mrna 18 gen dre ur", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0404U", "type": "HCPCS" } ], "description": "Onc brst semiq meas thym kn", "standard_charges": [ { "billing_class": "facility", "maximum": 1211.1, "minimum": 322.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 322.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1211.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1211.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0405U", "type": "HCPCS" } ], "description": "Onc pncrtc 59 mthltn blk mrk", "standard_charges": [ { "billing_class": "facility", "maximum": 6639.3, "minimum": 1770.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1770.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6639.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6639.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0406U", "type": "HCPCS" } ], "description": "Onc lung flow cytmtry 5 mrk", "standard_charges": [ { "billing_class": "facility", "maximum": 2850.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2850.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2850.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0407U", "type": "HCPCS" } ], "description": "Neph dbtc ckd mult eclia alg", "standard_charges": [ { "billing_class": "facility", "maximum": 3562.5, "minimum": 950.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 950.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3562.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3562.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0409U", "type": "HCPCS" } ], "description": "Onc sld tum dna 80 & rna 36", "standard_charges": [ { "billing_class": "facility", "maximum": 10948.5, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10948.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10948.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0410U", "type": "HCPCS" } ], "description": "Onc pncrtc dna whl gn seq 5-", "standard_charges": [ { "billing_class": "facility", "maximum": 4350.0, "minimum": 1160.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1160.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4350.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4350.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0411U", "type": "HCPCS" } ], "description": "Psyc genom alys pnl 15 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 5010.34, "minimum": 1336.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1336.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5010.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5010.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0413U", "type": "HCPCS" } ], "description": "Onc hl neo opt gen mapg dna", "standard_charges": [ { "billing_class": "facility", "maximum": 4738.24, "minimum": 1263.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1263.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4738.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4738.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0414U", "type": "HCPCS" } ], "description": "Onc lng aug alg aly whl sld8", "standard_charges": [ { "billing_class": "facility", "maximum": 2648.44, "minimum": 706.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2648.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2648.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0415U", "type": "HCPCS" } ], "description": "Cv ds acs bld alg 5 yr score", "standard_charges": [ { "billing_class": "facility", "maximum": 1465.31, "minimum": 390.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 390.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1465.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1465.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0416U", "type": "HCPCS" } ], "description": "Iadna gu pthgn 20bct&fng org", "standard_charges": [ { "billing_class": "facility", "maximum": 1562.93, "minimum": 1562.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1562.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1562.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0418U", "type": "HCPCS" } ], "description": "Onc brst aug alg aly whl sl8", "standard_charges": [ { "billing_class": "facility", "maximum": 2648.44, "minimum": 706.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2648.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2648.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0419U", "type": "HCPCS" } ], "description": "Nrpsyc gen seq vrnt aly 13", "standard_charges": [ { "billing_class": "facility", "maximum": 5010.34, "minimum": 1336.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1336.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 5010.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 5010.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0564T", "type": "HCPCS" } ], "description": "Onc chemo rx cytotox csc 14", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 188.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36415", "type": "HCPCS" } ], "description": "Routine venipuncture", "standard_charges": [ { "billing_class": "facility", "maximum": 32.14, "minimum": 9.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36416", "type": "HCPCS" } ], "description": "Capillary blood draw", "standard_charges": [ { "billing_class": "facility", "maximum": 31.76, "minimum": 31.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80047", "type": "HCPCS" } ], "description": "Metabolic panel ionized ca", "standard_charges": [ { "billing_class": "facility", "maximum": 51.49, "minimum": 13.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80048", "type": "HCPCS" } ], "description": "Metabolic panel total ca", "standard_charges": [ { "billing_class": "facility", "maximum": 31.73, "minimum": 8.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80050", "type": "HCPCS" } ], "description": "General health panel", "standard_charges": [ { "billing_class": "facility", "maximum": 152.48, "minimum": 152.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 152.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 152.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80051", "type": "HCPCS" } ], "description": "Electrolyte panel", "standard_charges": [ { "billing_class": "facility", "maximum": 26.29, "minimum": 7.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80053", "type": "HCPCS" } ], "description": "Comprehen metabolic panel", "standard_charges": [ { "billing_class": "facility", "maximum": 39.6, "minimum": 10.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80055", "type": "HCPCS" } ], "description": "Obstetric panel", "standard_charges": [ { "billing_class": "facility", "maximum": 179.29, "minimum": 47.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 179.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 179.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80061", "type": "HCPCS" } ], "description": "Lipid panel", "standard_charges": [ { "billing_class": "facility", "maximum": 50.21, "minimum": 13.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80069", "type": "HCPCS" } ], "description": "Renal function panel", "standard_charges": [ { "billing_class": "facility", "maximum": 32.55, "minimum": 8.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80074", "type": "HCPCS" } ], "description": "Acute hepatitis panel", "standard_charges": [ { "billing_class": "facility", "maximum": 178.61, "minimum": 47.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 178.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 178.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80076", "type": "HCPCS" } ], "description": "Hepatic function panel", "standard_charges": [ { "billing_class": "facility", "maximum": 30.64, "minimum": 8.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80081", "type": "HCPCS" } ], "description": "Obstetric panel", "standard_charges": [ { "billing_class": "facility", "maximum": 280.73, "minimum": 74.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 74.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 280.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 280.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80143", "type": "HCPCS" } ], "description": "Drug assay acetaminophen", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80145", "type": "HCPCS" } ], "description": "Drug assay adalimumab", "standard_charges": [ { "billing_class": "facility", "maximum": 144.64, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80150", "type": "HCPCS" } ], "description": "Assay of amikacin", "standard_charges": [ { "billing_class": "facility", "maximum": 56.55, "minimum": 15.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80151", "type": "HCPCS" } ], "description": "Drug assay amiodarone", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80155", "type": "HCPCS" } ], "description": "Drug assay caffeine", "standard_charges": [ { "billing_class": "facility", "maximum": 144.64, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80156", "type": "HCPCS" } ], "description": "Assay carbamazepine total", "standard_charges": [ { "billing_class": "facility", "maximum": 54.64, "minimum": 14.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80157", "type": "HCPCS" } ], "description": "Assay carbamazepine free", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80158", "type": "HCPCS" } ], "description": "Drug assay cyclosporine", "standard_charges": [ { "billing_class": "facility", "maximum": 67.69, "minimum": 18.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80159", "type": "HCPCS" } ], "description": "Drug assay clozapine", "standard_charges": [ { "billing_class": "facility", "maximum": 75.56, "minimum": 20.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80161", "type": "HCPCS" } ], "description": "Asy carbamazepin 10,11-epxid", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80162", "type": "HCPCS" } ], "description": "Assay of digoxin total", "standard_charges": [ { "billing_class": "facility", "maximum": 49.8, "minimum": 13.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80163", "type": "HCPCS" } ], "description": "Assay of digoxin free", "standard_charges": [ { "billing_class": "facility", "maximum": 49.8, "minimum": 13.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80164", "type": "HCPCS" } ], "description": "Assay dipropylacetic acd tot", "standard_charges": [ { "billing_class": "facility", "maximum": 50.78, "minimum": 13.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80165", "type": "HCPCS" } ], "description": "Dipropylacetic acid free", "standard_charges": [ { "billing_class": "facility", "maximum": 50.78, "minimum": 13.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80167", "type": "HCPCS" } ], "description": "Drug assay felbamate", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80168", "type": "HCPCS" } ], "description": "Assay of ethosuximide", "standard_charges": [ { "billing_class": "facility", "maximum": 61.28, "minimum": 16.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80169", "type": "HCPCS" } ], "description": "Drug assay everolimus", "standard_charges": [ { "billing_class": "facility", "maximum": 51.49, "minimum": 13.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80170", "type": "HCPCS" } ], "description": "Assay of gentamicin", "standard_charges": [ { "billing_class": "facility", "maximum": 61.43, "minimum": 16.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80171", "type": "HCPCS" } ], "description": "Drug screen quant gabapentin", "standard_charges": [ { "billing_class": "facility", "maximum": 81.26, "minimum": 21.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80173", "type": "HCPCS" } ], "description": "Assay Of Haloperidol", "standard_charges": [ { "billing_class": "facility", "maximum": 59.18, "minimum": 15.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80175", "type": "HCPCS" } ], "description": "Drug screen quan lamotrigine", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80176", "type": "HCPCS" } ], "description": "Assay of lidocaine", "standard_charges": [ { "billing_class": "facility", "maximum": 55.09, "minimum": 14.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80177", "type": "HCPCS" } ], "description": "Drug scrn quan levetiracetam", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80178", "type": "HCPCS" } ], "description": "Assay of lithium", "standard_charges": [ { "billing_class": "facility", "maximum": 24.79, "minimum": 6.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80179", "type": "HCPCS" } ], "description": "Drug assay salicylate", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80180", "type": "HCPCS" } ], "description": "Drug scrn quan mycophenolate", "standard_charges": [ { "billing_class": "facility", "maximum": 67.69, "minimum": 18.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80181", "type": "HCPCS" } ], "description": "Drug assay flecainide", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80183", "type": "HCPCS" } ], "description": "Drug scrn quant oxcarbazepin", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80184", "type": "HCPCS" } ], "description": "Assay of phenobarbital", "standard_charges": [ { "billing_class": "facility", "maximum": 57.38, "minimum": 15.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80185", "type": "HCPCS" } ], "description": "Assay of phenytoin total", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80186", "type": "HCPCS" } ], "description": "Assay of phenytoin free", "standard_charges": [ { "billing_class": "facility", "maximum": 51.6, "minimum": 13.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80187", "type": "HCPCS" } ], "description": "Drug assay posaconazole", "standard_charges": [ { "billing_class": "facility", "maximum": 101.66, "minimum": 27.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80188", "type": "HCPCS" } ], "description": "Assay of primidone", "standard_charges": [ { "billing_class": "facility", "maximum": 62.21, "minimum": 16.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80189", "type": "HCPCS" } ], "description": "Drug assay itraconzaole", "standard_charges": [ { "billing_class": "facility", "maximum": 101.66, "minimum": 27.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80190", "type": "HCPCS" } ], "description": "Assay of procainamide", "standard_charges": [ { "billing_class": "facility", "maximum": 225.0, "minimum": 60.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 225.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 225.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80192", "type": "HCPCS" } ], "description": "Assay of procainamide", "standard_charges": [ { "billing_class": "facility", "maximum": 62.81, "minimum": 16.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80193", "type": "HCPCS" } ], "description": "Drug assay leflunomide", "standard_charges": [ { "billing_class": "facility", "maximum": 144.64, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80194", "type": "HCPCS" } ], "description": "Assay of quinidine", "standard_charges": [ { "billing_class": "facility", "maximum": 54.75, "minimum": 14.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80195", "type": "HCPCS" } ], "description": "Assay of sirolimus", "standard_charges": [ { "billing_class": "facility", "maximum": 51.49, "minimum": 13.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80197", "type": "HCPCS" } ], "description": "Assay of tacrolimus", "standard_charges": [ { "billing_class": "facility", "maximum": 51.49, "minimum": 13.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80198", "type": "HCPCS" } ], "description": "Assay of theophylline", "standard_charges": [ { "billing_class": "facility", "maximum": 53.03, "minimum": 14.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80199", "type": "HCPCS" } ], "description": "Drug screen quant tiagabine", "standard_charges": [ { "billing_class": "facility", "maximum": 101.66, "minimum": 27.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80200", "type": "HCPCS" } ], "description": "Assay of tobramycin", "standard_charges": [ { "billing_class": "facility", "maximum": 60.49, "minimum": 16.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80201", "type": "HCPCS" } ], "description": "Assay of topiramate", "standard_charges": [ { "billing_class": "facility", "maximum": 44.7, "minimum": 11.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80202", "type": "HCPCS" } ], "description": "Assay of vancomycin", "standard_charges": [ { "billing_class": "facility", "maximum": 50.78, "minimum": 13.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80203", "type": "HCPCS" } ], "description": "Drug screen quant zonisamide", "standard_charges": [ { "billing_class": "facility", "maximum": 49.69, "minimum": 13.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80204", "type": "HCPCS" } ], "description": "Drug assay methotrexate", "standard_charges": [ { "billing_class": "facility", "maximum": 144.64, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80210", "type": "HCPCS" } ], "description": "Drug assay rufinamide", "standard_charges": [ { "billing_class": "facility", "maximum": 101.66, "minimum": 27.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80220", "type": "HCPCS" } ], "description": "Drug asy hydroxychloroquine", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80230", "type": "HCPCS" } ], "description": "Drug assay infliximab", "standard_charges": [ { "billing_class": "facility", "maximum": 144.64, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80235", "type": "HCPCS" } ], "description": "Drug assay lacosamide", "standard_charges": [ { "billing_class": "facility", "maximum": 101.66, "minimum": 27.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80280", "type": "HCPCS" } ], "description": "Drug assay vedolizumab", "standard_charges": [ { "billing_class": "facility", "maximum": 144.64, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80285", "type": "HCPCS" } ], "description": "Drug assay voriconazole", "standard_charges": [ { "billing_class": "facility", "maximum": 101.66, "minimum": 27.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80299", "type": "HCPCS" } ], "description": "Quantitative assay drug", "standard_charges": [ { "billing_class": "facility", "maximum": 69.9, "minimum": 18.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80305", "type": "HCPCS" } ], "description": "Drug test prsmv dir opt obs", "standard_charges": [ { "billing_class": "facility", "maximum": 47.25, "minimum": 12.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80306", "type": "HCPCS" } ], "description": "Drug test prsmv instrmnt", "standard_charges": [ { "billing_class": "facility", "maximum": 64.28, "minimum": 17.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80307", "type": "HCPCS" } ], "description": "Drug test prsmv chem anlyzr", "standard_charges": [ { "billing_class": "facility", "maximum": 233.03, "minimum": 62.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 233.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 233.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80400", "type": "HCPCS" } ], "description": "Acth stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 122.33, "minimum": 32.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 122.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 122.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80402", "type": "HCPCS" } ], "description": "Acth stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 326.1, "minimum": 86.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 326.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 326.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80406", "type": "HCPCS" } ], "description": "Acth stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 293.48, "minimum": 78.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 293.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 293.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80408", "type": "HCPCS" } ], "description": "Aldosterone suppression eval", "standard_charges": [ { "billing_class": "facility", "maximum": 470.63, "minimum": 125.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 125.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 470.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 470.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80410", "type": "HCPCS" } ], "description": "Calcitonin stimul panel", "standard_charges": [ { "billing_class": "facility", "maximum": 301.39, "minimum": 80.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 80.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 301.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 301.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80412", "type": "HCPCS" } ], "description": "CRH stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 3006.08, "minimum": 801.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 801.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3006.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3006.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80414", "type": "HCPCS" } ], "description": "Testosterone response", "standard_charges": [ { "billing_class": "facility", "maximum": 193.65, "minimum": 51.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 193.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 193.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80415", "type": "HCPCS" } ], "description": "Estradiol response panel", "standard_charges": [ { "billing_class": "facility", "maximum": 209.59, "minimum": 55.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 209.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 209.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80416", "type": "HCPCS" } ], "description": "Renin stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 784.95, "minimum": 209.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 209.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 784.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 784.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80417", "type": "HCPCS" } ], "description": "Renin stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 164.96, "minimum": 43.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 164.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 164.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80418", "type": "HCPCS" } ], "description": "Pituitary evaluation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 2173.05, "minimum": 579.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 579.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2173.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2173.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80420", "type": "HCPCS" } ], "description": "Dexamethasone panel", "standard_charges": [ { "billing_class": "facility", "maximum": 607.05, "minimum": 161.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 161.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 607.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 607.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80422", "type": "HCPCS" } ], "description": "Glucagon tolerance panel", "standard_charges": [ { "billing_class": "facility", "maximum": 172.76, "minimum": 46.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 172.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 172.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80424", "type": "HCPCS" } ], "description": "Glucagon tolerance panel", "standard_charges": [ { "billing_class": "facility", "maximum": 189.38, "minimum": 50.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 189.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 189.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80426", "type": "HCPCS" } ], "description": "Gonadotropin hormone panel", "standard_charges": [ { "billing_class": "facility", "maximum": 556.54, "minimum": 148.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 148.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 556.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 556.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80428", "type": "HCPCS" } ], "description": "Growth hormone panel", "standard_charges": [ { "billing_class": "facility", "maximum": 250.13, "minimum": 66.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 250.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 250.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80430", "type": "HCPCS" } ], "description": "Growth hormone panel", "standard_charges": [ { "billing_class": "facility", "maximum": 484.99, "minimum": 129.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 484.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 484.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80432", "type": "HCPCS" } ], "description": "Insulin suppression panel", "standard_charges": [ { "billing_class": "facility", "maximum": 621.04, "minimum": 165.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 165.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 621.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 621.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80434", "type": "HCPCS" } ], "description": "Insulin tolerance panel", "standard_charges": [ { "billing_class": "facility", "maximum": 1068.86, "minimum": 285.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 285.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1068.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1068.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80435", "type": "HCPCS" } ], "description": "Insulin tolerance panel", "standard_charges": [ { "billing_class": "facility", "maximum": 386.25, "minimum": 103.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 103.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 386.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 386.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80436", "type": "HCPCS" } ], "description": "Metyrapone panel", "standard_charges": [ { "billing_class": "facility", "maximum": 341.85, "minimum": 91.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 341.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 341.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80438", "type": "HCPCS" } ], "description": "TRH stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 189.04, "minimum": 50.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 189.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 189.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80439", "type": "HCPCS" } ], "description": "TRH stimulation panel", "standard_charges": [ { "billing_class": "facility", "maximum": 252.04, "minimum": 67.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 67.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 252.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 252.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80503", "type": "HCPCS" } ], "description": "Path clin consltj sf 5-20", "standard_charges": [ { "billing_class": "facility", "maximum": 188.03, "minimum": 50.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 188.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 188.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80504", "type": "HCPCS" } ], "description": "Path clin consltj mod 21-40", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80505", "type": "HCPCS" } ], "description": "Path clin consltj high 41-60", "standard_charges": [ { "billing_class": "facility", "maximum": 589.69, "minimum": 164.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 164.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 589.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 589.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "80506", "type": "HCPCS" } ], "description": "Path clin consltj prolng svc", "standard_charges": [ { "billing_class": "facility", "maximum": 161.4, "minimum": 161.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 161.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 161.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81000", "type": "HCPCS" } ], "description": "Urinalysis nonauto w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15.08, "minimum": 4.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81001", "type": "HCPCS" } ], "description": "Urinalysis auto w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 11.89, "minimum": 3.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81002", "type": "HCPCS" } ], "description": "Urinalysis nonauto w/o scope", "standard_charges": [ { "billing_class": "facility", "maximum": 13.05, "minimum": 3.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81003", "type": "HCPCS" } ], "description": "Urinalysis auto w/o scope", "standard_charges": [ { "billing_class": "facility", "maximum": 8.44, "minimum": 2.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81005", "type": "HCPCS" } ], "description": "Urinalysis", "standard_charges": [ { "billing_class": "facility", "maximum": 8.14, "minimum": 2.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81007", "type": "HCPCS" } ], "description": "Urine screen for bacteria", "standard_charges": [ { "billing_class": "facility", "maximum": 112.43, "minimum": 29.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81015", "type": "HCPCS" } ], "description": "Microscopic exam of urine", "standard_charges": [ { "billing_class": "facility", "maximum": 11.44, "minimum": 3.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81020", "type": "HCPCS" } ], "description": "Urinalysis glass test", "standard_charges": [ { "billing_class": "facility", "maximum": 17.63, "minimum": 4.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81025", "type": "HCPCS" } ], "description": "Urine pregnancy test", "standard_charges": [ { "billing_class": "facility", "maximum": 32.29, "minimum": 8.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81050", "type": "HCPCS" } ], "description": "Urinalysis volume measure", "standard_charges": [ { "billing_class": "facility", "maximum": 13.65, "minimum": 3.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81105", "type": "HCPCS" } ], "description": "Hpa-1 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81106", "type": "HCPCS" } ], "description": "Hpa-2 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81107", "type": "HCPCS" } ], "description": "Hpa-3 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81108", "type": "HCPCS" } ], "description": "Hpa-4 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81109", "type": "HCPCS" } ], "description": "Hpa-5 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81110", "type": "HCPCS" } ], "description": "Hpa-6 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81111", "type": "HCPCS" } ], "description": "Hpa-9 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81112", "type": "HCPCS" } ], "description": "Hpa-15 genotyping", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81120", "type": "HCPCS" } ], "description": "Idh1 common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 724.69, "minimum": 193.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 724.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 724.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81121", "type": "HCPCS" } ], "description": "Idh2 common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1109.21, "minimum": 295.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1109.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1109.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81161", "type": "HCPCS" } ], "description": "DMD dup/delet analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1046.25, "minimum": 279.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 279.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1046.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1046.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81162", "type": "HCPCS" } ], "description": "Brca1&2 seq & full dup/del", "standard_charges": [ { "billing_class": "facility", "maximum": 6843.3, "minimum": 1824.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1824.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 6843.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 6843.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81163", "type": "HCPCS" } ], "description": "Brca1&2 gene full seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1755.0, "minimum": 468.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 468.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1755.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1755.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81164", "type": "HCPCS" } ], "description": "Brca1&2 gen ful dup/del alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2190.86, "minimum": 584.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2190.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2190.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81165", "type": "HCPCS" } ], "description": "Brca1 gene full seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81166", "type": "HCPCS" } ], "description": "Brca1 gene full dup/del alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1130.06, "minimum": 301.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 301.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1130.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1130.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81167", "type": "HCPCS" } ], "description": "Brca2 gene full dup/del alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81168", "type": "HCPCS" } ], "description": "Ccnd1/igh translocation alys", "standard_charges": [ { "billing_class": "facility", "maximum": 777.41, "minimum": 207.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81170", "type": "HCPCS" } ], "description": "Abl1 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 1125.0, "minimum": 300.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 300.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1125.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1125.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81171", "type": "HCPCS" } ], "description": "Aff2 gene detc abnor alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81172", "type": "HCPCS" } ], "description": "Aff2 gene charac alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81173", "type": "HCPCS" } ], "description": "Ar gene full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 1130.06, "minimum": 301.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 301.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1130.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1130.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81174", "type": "HCPCS" } ], "description": "Ar gene known famil variant", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81175", "type": "HCPCS" } ], "description": "Asxl1 full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2536.88, "minimum": 676.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 676.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2536.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2536.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81176", "type": "HCPCS" } ], "description": "Asxl1 gene target seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 907.13, "minimum": 241.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 241.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 907.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 907.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81177", "type": "HCPCS" } ], "description": "Atn1 gene detc abnor alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81178", "type": "HCPCS" } ], "description": "Atxn1 gene detc abnor allele", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81179", "type": "HCPCS" } ], "description": "Atxn2 gene detc abnor allele", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81180", "type": "HCPCS" } ], "description": "Atxn3 gene detc abnor allele", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81181", "type": "HCPCS" } ], "description": "Atxn7 gene detc abnor allele", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81182", "type": "HCPCS" } ], "description": "Atxn8os gen detc abnor allel", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81183", "type": "HCPCS" } ], "description": "Atxn10 gene detc abnor allel", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81184", "type": "HCPCS" } ], "description": "Cacna1a gen detc abnor allel", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81185", "type": "HCPCS" } ], "description": "Cacna1a gene full gene seq", "standard_charges": [ { "billing_class": "facility", "maximum": 3173.51, "minimum": 846.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 846.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3173.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3173.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81186", "type": "HCPCS" } ], "description": "Cacna1a gen known famil vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81187", "type": "HCPCS" } ], "description": "Cnbp gene detc abnor allele", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81188", "type": "HCPCS" } ], "description": "Cstb gene detc abnor allele", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81189", "type": "HCPCS" } ], "description": "Cstb gene full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81190", "type": "HCPCS" } ], "description": "Cstb gene known famil vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81191", "type": "HCPCS" } ], "description": "Ntrk1 translocation analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 777.41, "minimum": 207.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81192", "type": "HCPCS" } ], "description": "Ntrk2 translocation analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 777.41, "minimum": 207.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81193", "type": "HCPCS" } ], "description": "Ntrk3 translocation analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 777.41, "minimum": 207.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81194", "type": "HCPCS" } ], "description": "Ntrk translocation analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 1943.55, "minimum": 518.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 518.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1943.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1943.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81200", "type": "HCPCS" } ], "description": "Aspa gene", "standard_charges": [ { "billing_class": "facility", "maximum": 177.19, "minimum": 47.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 177.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 177.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81201", "type": "HCPCS" } ], "description": "Apc gene full sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2925.0, "minimum": 780.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 780.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2925.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2925.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81202", "type": "HCPCS" } ], "description": "Apc gene known fam variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1050.0, "minimum": 280.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 280.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1050.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1050.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81203", "type": "HCPCS" } ], "description": "Apc gene dup/delet variants", "standard_charges": [ { "billing_class": "facility", "maximum": 750.0, "minimum": 200.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 200.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 750.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 750.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81204", "type": "HCPCS" } ], "description": "Ar gene charac alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81205", "type": "HCPCS" } ], "description": "Bckdhb gene", "standard_charges": [ { "billing_class": "facility", "maximum": 356.21, "minimum": 94.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 356.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 356.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81206", "type": "HCPCS" } ], "description": "Bcr/abl1 gene major bp", "standard_charges": [ { "billing_class": "facility", "maximum": 614.85, "minimum": 163.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 163.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 614.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 614.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81207", "type": "HCPCS" } ], "description": "Bcr/abl1 gene minor bp", "standard_charges": [ { "billing_class": "facility", "maximum": 543.15, "minimum": 144.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 144.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 543.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 543.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81208", "type": "HCPCS" } ], "description": "Bcr/abl1 gene other bp", "standard_charges": [ { "billing_class": "facility", "maximum": 804.83, "minimum": 214.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 214.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 804.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 804.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81209", "type": "HCPCS" } ], "description": "Blm gene", "standard_charges": [ { "billing_class": "facility", "maximum": 147.41, "minimum": 39.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 147.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81210", "type": "HCPCS" } ], "description": "Braf gene", "standard_charges": [ { "billing_class": "facility", "maximum": 657.75, "minimum": 175.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 175.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 657.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 657.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81212", "type": "HCPCS" } ], "description": "Brca1&2 185&5385&6174 var", "standard_charges": [ { "billing_class": "facility", "maximum": 1650.0, "minimum": 440.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 440.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1650.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1650.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81215", "type": "HCPCS" } ], "description": "Brca1 gene known fam variant", "standard_charges": [ { "billing_class": "facility", "maximum": 1407.19, "minimum": 375.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 375.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1407.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1407.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81216", "type": "HCPCS" } ], "description": "Brca2 gene full sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 694.2, "minimum": 185.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81217", "type": "HCPCS" } ], "description": "Brca2 gene known fam variant", "standard_charges": [ { "billing_class": "facility", "maximum": 1407.19, "minimum": 375.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 375.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1407.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1407.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81218", "type": "HCPCS" } ], "description": "Cebpa gene full sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 907.13, "minimum": 241.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 241.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 907.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 907.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81219", "type": "HCPCS" } ], "description": "Calr gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 456.11, "minimum": 121.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 121.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 456.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 456.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81220", "type": "HCPCS" } ], "description": "Cftr gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 2087.25, "minimum": 556.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 556.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2087.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2087.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81221", "type": "HCPCS" } ], "description": "Cftr gene known fam variants", "standard_charges": [ { "billing_class": "facility", "maximum": 364.58, "minimum": 97.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 364.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 364.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81222", "type": "HCPCS" } ], "description": "Cftr gene dup/delet variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1631.51, "minimum": 435.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 435.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1631.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1631.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81223", "type": "HCPCS" } ], "description": "Cftr gene full sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 1871.25, "minimum": 499.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 499.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1871.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1871.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81224", "type": "HCPCS" } ], "description": "Cftr gene intron poly t", "standard_charges": [ { "billing_class": "facility", "maximum": 632.81, "minimum": 168.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 168.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 632.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 632.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81225", "type": "HCPCS" } ], "description": "Cyp2c19 gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1092.6, "minimum": 291.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 291.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1092.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1092.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81226", "type": "HCPCS" } ], "description": "Cyp2d6 gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1690.91, "minimum": 450.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 450.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1690.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1690.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81227", "type": "HCPCS" } ], "description": "Cyp2c9 gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81228", "type": "HCPCS" } ], "description": "Cytogen micrarray copy nmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 3375.0, "minimum": 900.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 900.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3375.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3375.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81229", "type": "HCPCS" } ], "description": "Cytogen m array copy no&snp", "standard_charges": [ { "billing_class": "facility", "maximum": 4350.0, "minimum": 1160.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1160.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4350.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4350.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81230", "type": "HCPCS" } ], "description": "Cyp3a4 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81231", "type": "HCPCS" } ], "description": "Cyp3a5 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81232", "type": "HCPCS" } ], "description": "Dpyd gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81233", "type": "HCPCS" } ], "description": "Btk gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 657.75, "minimum": 175.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 175.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 657.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 657.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81234", "type": "HCPCS" } ], "description": "Dmpk gene detc abnor allele", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81235", "type": "HCPCS" } ], "description": "Egfr gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1217.18, "minimum": 324.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 324.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1217.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1217.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81236", "type": "HCPCS" } ], "description": "Ezh2 gene full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81237", "type": "HCPCS" } ], "description": "Ezh2 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 657.75, "minimum": 175.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 175.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 657.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 657.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81238", "type": "HCPCS" } ], "description": "F9 full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2250.0, "minimum": 600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2250.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2250.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81239", "type": "HCPCS" } ], "description": "Dmpk gene charac alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81240", "type": "HCPCS" } ], "description": "F2 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 246.34, "minimum": 65.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 65.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 246.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 246.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81241", "type": "HCPCS" } ], "description": "F5 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 275.14, "minimum": 73.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 275.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 275.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81242", "type": "HCPCS" } ], "description": "Fancc gene", "standard_charges": [ { "billing_class": "facility", "maximum": 137.33, "minimum": 36.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 137.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 137.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81243", "type": "HCPCS" } ], "description": "Fmr1 gene detection", "standard_charges": [ { "billing_class": "facility", "maximum": 213.9, "minimum": 57.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 213.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 213.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81244", "type": "HCPCS" } ], "description": "Fmr1 gene characterization", "standard_charges": [ { "billing_class": "facility", "maximum": 168.34, "minimum": 44.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 168.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 168.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81245", "type": "HCPCS" } ], "description": "Flt3 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 620.66, "minimum": 165.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 165.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 620.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 620.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81246", "type": "HCPCS" } ], "description": "Flt3 gene analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 311.25, "minimum": 83.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 311.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 311.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81247", "type": "HCPCS" } ], "description": "G6pd gene alys cmn variant", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81248", "type": "HCPCS" } ], "description": "G6pd known familial variant", "standard_charges": [ { "billing_class": "facility", "maximum": 1407.19, "minimum": 375.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 375.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1407.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1407.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81249", "type": "HCPCS" } ], "description": "G6pd full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2250.0, "minimum": 600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2250.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2250.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81250", "type": "HCPCS" } ], "description": "G6pc gene", "standard_charges": [ { "billing_class": "facility", "maximum": 219.34, "minimum": 58.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 219.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 219.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81251", "type": "HCPCS" } ], "description": "Gba gene", "standard_charges": [ { "billing_class": "facility", "maximum": 177.19, "minimum": 47.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 177.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 177.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81252", "type": "HCPCS" } ], "description": "Gjb2 gene full sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 379.2, "minimum": 101.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 379.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 379.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81253", "type": "HCPCS" } ], "description": "Gjb2 gene known fam variants", "standard_charges": [ { "billing_class": "facility", "maximum": 230.7, "minimum": 61.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 230.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 230.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81254", "type": "HCPCS" } ], "description": "Gjb6 gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 131.25, "minimum": 35.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81255", "type": "HCPCS" } ], "description": "Hexa gene", "standard_charges": [ { "billing_class": "facility", "maximum": 192.94, "minimum": 51.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 192.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81256", "type": "HCPCS" } ], "description": "Hfe gene", "standard_charges": [ { "billing_class": "facility", "maximum": 245.1, "minimum": 65.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 65.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 245.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 245.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81257", "type": "HCPCS" } ], "description": "Hba1/hba2 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 383.48, "minimum": 102.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 102.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 383.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 383.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81258", "type": "HCPCS" } ], "description": "Hba1/hba2 gene fam vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 1407.19, "minimum": 375.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 375.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1407.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1407.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81259", "type": "HCPCS" } ], "description": "Hba1/hba2 full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2250.0, "minimum": 600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2250.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2250.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81260", "type": "HCPCS" } ], "description": "Ikbkap gene", "standard_charges": [ { "billing_class": "facility", "maximum": 147.41, "minimum": 39.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 147.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81261", "type": "HCPCS" } ], "description": "Igh gene rearrange amp meth", "standard_charges": [ { "billing_class": "facility", "maximum": 742.46, "minimum": 197.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 197.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 742.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 742.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81262", "type": "HCPCS" } ], "description": "Igh gene rearrang dir probe", "standard_charges": [ { "billing_class": "facility", "maximum": 257.06, "minimum": 68.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 257.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 257.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81263", "type": "HCPCS" } ], "description": "Igh vari regional mutation", "standard_charges": [ { "billing_class": "facility", "maximum": 1104.45, "minimum": 294.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 294.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1104.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1104.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81264", "type": "HCPCS" } ], "description": "Igk rearrangeabn clonal pop", "standard_charges": [ { "billing_class": "facility", "maximum": 647.74, "minimum": 172.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 172.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 647.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 647.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81265", "type": "HCPCS" } ], "description": "Str markers specimen anal", "standard_charges": [ { "billing_class": "facility", "maximum": 874.01, "minimum": 233.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 233.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 874.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 874.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81266", "type": "HCPCS" } ], "description": "Str markers spec anal addl", "standard_charges": [ { "billing_class": "facility", "maximum": 1143.04, "minimum": 304.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 304.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1143.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1143.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81267", "type": "HCPCS" } ], "description": "Chimerism anal no cell selec", "standard_charges": [ { "billing_class": "facility", "maximum": 777.98, "minimum": 207.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81268", "type": "HCPCS" } ], "description": "Chimerism anal w/cell select", "standard_charges": [ { "billing_class": "facility", "maximum": 977.96, "minimum": 260.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 977.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 977.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81269", "type": "HCPCS" } ], "description": "Hba1/hba2 gene dup/del vrnts", "standard_charges": [ { "billing_class": "facility", "maximum": 759.0, "minimum": 202.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 202.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 759.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 759.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81270", "type": "HCPCS" } ], "description": "Jak2 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 343.73, "minimum": 91.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 343.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 343.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81271", "type": "HCPCS" } ], "description": "Htt gene detc abnor alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81272", "type": "HCPCS" } ], "description": "Kit gene targeted seq analys", "standard_charges": [ { "billing_class": "facility", "maximum": 1235.66, "minimum": 329.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 329.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1235.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1235.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81273", "type": "HCPCS" } ], "description": "Kit gene analys d816 variant", "standard_charges": [ { "billing_class": "facility", "maximum": 468.26, "minimum": 124.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 468.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 468.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81274", "type": "HCPCS" } ], "description": "Htt gene charac alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81275", "type": "HCPCS" } ], "description": "Kras gene variants exon 2", "standard_charges": [ { "billing_class": "facility", "maximum": 724.69, "minimum": 193.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 724.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 724.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81276", "type": "HCPCS" } ], "description": "Kras gene addl variants", "standard_charges": [ { "billing_class": "facility", "maximum": 724.69, "minimum": 193.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 724.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 724.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81277", "type": "HCPCS" } ], "description": "Cytogenomic neo microra alys", "standard_charges": [ { "billing_class": "facility", "maximum": 4350.0, "minimum": 1160.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1160.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4350.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4350.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81278", "type": "HCPCS" } ], "description": "Igh@/bcl2 translocation alys", "standard_charges": [ { "billing_class": "facility", "maximum": 777.41, "minimum": 207.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81279", "type": "HCPCS" } ], "description": "Jak2 gene trgt sequence alys", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81283", "type": "HCPCS" } ], "description": "Ifnl3 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 275.14, "minimum": 73.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 275.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 275.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81284", "type": "HCPCS" } ], "description": "Fxn gene detc abnor alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81285", "type": "HCPCS" } ], "description": "Fxn gene charac alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81286", "type": "HCPCS" } ], "description": "Fxn gene full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81287", "type": "HCPCS" } ], "description": "Mgmt gene methylation anal", "standard_charges": [ { "billing_class": "facility", "maximum": 467.4, "minimum": 124.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 467.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 467.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81288", "type": "HCPCS" } ], "description": "Mlh1 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 721.2, "minimum": 192.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 721.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 721.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81289", "type": "HCPCS" } ], "description": "Fxn gene known famil variant", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81290", "type": "HCPCS" } ], "description": "Mcoln1 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 147.41, "minimum": 39.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 147.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81291", "type": "HCPCS" } ], "description": "Mthfr gene", "standard_charges": [ { "billing_class": "facility", "maximum": 245.03, "minimum": 65.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 65.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 245.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 245.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81292", "type": "HCPCS" } ], "description": "Mlh1 gene full seq", "standard_charges": [ { "billing_class": "facility", "maximum": 2532.75, "minimum": 675.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 675.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2532.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2532.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81293", "type": "HCPCS" } ], "description": "Mlh1 gene known variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1241.25, "minimum": 331.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 331.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1241.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1241.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81294", "type": "HCPCS" } ], "description": "Mlh1 gene dup/delete variant", "standard_charges": [ { "billing_class": "facility", "maximum": 759.0, "minimum": 202.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 202.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 759.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 759.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81295", "type": "HCPCS" } ], "description": "Msh2 gene full seq", "standard_charges": [ { "billing_class": "facility", "maximum": 1431.38, "minimum": 381.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 381.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1431.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1431.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81296", "type": "HCPCS" } ], "description": "Msh2 gene known variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1266.49, "minimum": 337.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 337.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1266.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1266.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81297", "type": "HCPCS" } ], "description": "Msh2 gene dup/delete variant", "standard_charges": [ { "billing_class": "facility", "maximum": 799.88, "minimum": 213.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 213.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 799.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 799.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81298", "type": "HCPCS" } ], "description": "Msh6 gene full seq", "standard_charges": [ { "billing_class": "facility", "maximum": 2406.94, "minimum": 641.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 641.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2406.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2406.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81299", "type": "HCPCS" } ], "description": "Msh6 gene known variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1155.0, "minimum": 308.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 308.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1155.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1155.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81300", "type": "HCPCS" } ], "description": "Msh6 gene dup/delete variant", "standard_charges": [ { "billing_class": "facility", "maximum": 892.5, "minimum": 238.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 238.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 892.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 892.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81301", "type": "HCPCS" } ], "description": "Microsatellite instability", "standard_charges": [ { "billing_class": "facility", "maximum": 1307.1, "minimum": 348.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 348.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1307.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1307.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81302", "type": "HCPCS" } ], "description": "Mecp2 gene full seq", "standard_charges": [ { "billing_class": "facility", "maximum": 1979.51, "minimum": 527.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 527.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1979.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1979.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81303", "type": "HCPCS" } ], "description": "Mecp2 gene known variant", "standard_charges": [ { "billing_class": "facility", "maximum": 450.0, "minimum": 120.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 120.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 450.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 450.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81304", "type": "HCPCS" } ], "description": "Mecp2 gene dup/delet variant", "standard_charges": [ { "billing_class": "facility", "maximum": 562.5, "minimum": 150.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 562.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 562.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81305", "type": "HCPCS" } ], "description": "Myd88 gene p.leu265pro vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 657.75, "minimum": 175.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 175.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 657.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 657.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81306", "type": "HCPCS" } ], "description": "Nudt15 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1092.6, "minimum": 291.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 291.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1092.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1092.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81307", "type": "HCPCS" } ], "description": "Palb2 gene full gene seq", "standard_charges": [ { "billing_class": "facility", "maximum": 2536.88, "minimum": 676.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 676.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2536.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2536.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81308", "type": "HCPCS" } ], "description": "Palb2 gene known famil vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 1130.06, "minimum": 301.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 301.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1130.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1130.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81309", "type": "HCPCS" } ], "description": "Pik3ca gene trgt seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81310", "type": "HCPCS" } ], "description": "Npm1 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 924.45, "minimum": 246.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 924.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 924.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81311", "type": "HCPCS" } ], "description": "Nras gene variants exon 2&3", "standard_charges": [ { "billing_class": "facility", "maximum": 1109.21, "minimum": 295.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1109.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1109.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81312", "type": "HCPCS" } ], "description": "Pabpn1 gene detc abnor allel", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81313", "type": "HCPCS" } ], "description": "Pca3/klk3 antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 956.44, "minimum": 255.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 255.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 956.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 956.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81314", "type": "HCPCS" } ], "description": "Pdgfra gene", "standard_charges": [ { "billing_class": "facility", "maximum": 1235.66, "minimum": 329.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 329.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1235.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1235.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81315", "type": "HCPCS" } ], "description": "Pml/raralpha com breakpoints", "standard_charges": [ { "billing_class": "facility", "maximum": 777.41, "minimum": 207.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81316", "type": "HCPCS" } ], "description": "Pml/raralpha 1 breakpoint", "standard_charges": [ { "billing_class": "facility", "maximum": 777.41, "minimum": 207.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 207.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 777.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 777.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81317", "type": "HCPCS" } ], "description": "Pms2 gene full seq analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 2536.88, "minimum": 676.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 676.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2536.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2536.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81318", "type": "HCPCS" } ], "description": "Pms2 known familial variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1241.25, "minimum": 331.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 331.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1241.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1241.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81319", "type": "HCPCS" } ], "description": "Pms2 gene dup/delet variants", "standard_charges": [ { "billing_class": "facility", "maximum": 763.13, "minimum": 203.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 203.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 763.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 763.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81320", "type": "HCPCS" } ], "description": "Plcg2 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 1092.6, "minimum": 291.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 291.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1092.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1092.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81321", "type": "HCPCS" } ], "description": "Pten gene full sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2250.0, "minimum": 600.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 600.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2250.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2250.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81322", "type": "HCPCS" } ], "description": "Pten gene known fam variant", "standard_charges": [ { "billing_class": "facility", "maximum": 174.75, "minimum": 46.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 174.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 174.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81323", "type": "HCPCS" } ], "description": "Pten gene dup/delet variant", "standard_charges": [ { "billing_class": "facility", "maximum": 1125.0, "minimum": 300.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 300.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1125.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1125.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81324", "type": "HCPCS" } ], "description": "Pmp22 gene dup/delet", "standard_charges": [ { "billing_class": "facility", "maximum": 2843.85, "minimum": 758.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 758.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2843.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2843.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81325", "type": "HCPCS" } ], "description": "Pmp22 gene full sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2885.93, "minimum": 769.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 769.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2885.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2885.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81326", "type": "HCPCS" } ], "description": "Pmp22 gene known fam variant", "standard_charges": [ { "billing_class": "facility", "maximum": 174.75, "minimum": 46.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 174.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 174.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81327", "type": "HCPCS" } ], "description": "Sept9 methylation analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 720.0, "minimum": 192.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 720.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 720.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81328", "type": "HCPCS" } ], "description": "Slco1b1 gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81329", "type": "HCPCS" } ], "description": "Smn1 gene dos/deletion alys", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81330", "type": "HCPCS" } ], "description": "Smpd1 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 176.25, "minimum": 47.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 176.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 176.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81331", "type": "HCPCS" } ], "description": "Snrpn/ube3a gene", "standard_charges": [ { "billing_class": "facility", "maximum": 191.51, "minimum": 51.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 191.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 191.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81332", "type": "HCPCS" } ], "description": "Serpina1 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 163.69, "minimum": 43.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 163.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 163.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81333", "type": "HCPCS" } ], "description": "Tgfbi gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81334", "type": "HCPCS" } ], "description": "Runx1 gene targeted seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1235.66, "minimum": 329.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 329.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1235.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1235.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81335", "type": "HCPCS" } ], "description": "Tpmt gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81336", "type": "HCPCS" } ], "description": "Smn1 gene full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 1130.06, "minimum": 301.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 301.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1130.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1130.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81337", "type": "HCPCS" } ], "description": "Smn1 gen nown famil seq vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81338", "type": "HCPCS" } ], "description": "Mpl gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 563.74, "minimum": 150.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 563.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 563.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81339", "type": "HCPCS" } ], "description": "Mpl gene seq alys exon 10", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81340", "type": "HCPCS" } ], "description": "Trb@ gene rearrange amplify", "standard_charges": [ { "billing_class": "facility", "maximum": 783.45, "minimum": 208.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 783.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 783.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81341", "type": "HCPCS" } ], "description": "Trb@ gene rearrange dirprobe", "standard_charges": [ { "billing_class": "facility", "maximum": 185.96, "minimum": 49.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 49.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 185.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 185.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81342", "type": "HCPCS" } ], "description": "Trg gene rearrangement anal", "standard_charges": [ { "billing_class": "facility", "maximum": 755.63, "minimum": 201.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 201.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 755.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 755.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81343", "type": "HCPCS" } ], "description": "Ppp2r2b gen detc abnor allel", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81344", "type": "HCPCS" } ], "description": "Tbp gene detc abnor alleles", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81345", "type": "HCPCS" } ], "description": "Tert gene targeted seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81346", "type": "HCPCS" } ], "description": "Tyms gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81347", "type": "HCPCS" } ], "description": "Sf3b1 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 724.69, "minimum": 193.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 724.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 724.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81348", "type": "HCPCS" } ], "description": "Srsf2 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 657.75, "minimum": 175.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 175.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 657.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 657.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81349", "type": "HCPCS" } ], "description": "Cytog alys chrml abnr lw-ps", "standard_charges": [ { "billing_class": "facility", "maximum": 4350.0, "minimum": 1197.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1197.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4350.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 4350.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81350", "type": "HCPCS" } ], "description": "Ugt1a1 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 877.5, "minimum": 234.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 234.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 877.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 877.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81351", "type": "HCPCS" } ], "description": "Tp53 gene full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 2406.94, "minimum": 641.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 641.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 2406.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 2406.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81352", "type": "HCPCS" } ], "description": "Tp53 gene trgt sequence alys", "standard_charges": [ { "billing_class": "facility", "maximum": 1235.66, "minimum": 329.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 329.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1235.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1235.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81353", "type": "HCPCS" } ], "description": "Tp53 gene known famil vrnt", "standard_charges": [ { "billing_class": "facility", "maximum": 1155.0, "minimum": 308.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 308.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1155.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1155.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81355", "type": "HCPCS" } ], "description": "Vkorc1 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 330.75, "minimum": 88.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 88.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 330.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 330.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81357", "type": "HCPCS" } ], "description": "U2af1 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 724.69, "minimum": 193.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 724.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 724.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81360", "type": "HCPCS" } ], "description": "Zrsr2 gene common variants", "standard_charges": [ { "billing_class": "facility", "maximum": 724.69, "minimum": 193.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 724.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 724.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81361", "type": "HCPCS" } ], "description": "Hbb gene com variants", "standard_charges": [ { "billing_class": "facility", "maximum": 655.54, "minimum": 174.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 655.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 655.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81362", "type": "HCPCS" } ], "description": "Hbb gene known fam variant", "standard_charges": [ { "billing_class": "facility", "maximum": 1407.19, "minimum": 375.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 375.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1407.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1407.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81363", "type": "HCPCS" } ], "description": "Hbb gene dup/del variants", "standard_charges": [ { "billing_class": "facility", "maximum": 759.0, "minimum": 202.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 202.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 759.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 759.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81364", "type": "HCPCS" } ], "description": "Hbb full gene sequence", "standard_charges": [ { "billing_class": "facility", "maximum": 1217.18, "minimum": 324.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 324.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1217.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1217.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81370", "type": "HCPCS" } ], "description": "Hla i & ii typing lr", "standard_charges": [ { "billing_class": "facility", "maximum": 1507.95, "minimum": 402.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 402.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1507.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1507.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81371", "type": "HCPCS" } ], "description": "Hla i & ii type verify lr", "standard_charges": [ { "billing_class": "facility", "maximum": 1516.95, "minimum": 404.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 404.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1516.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1516.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81372", "type": "HCPCS" } ], "description": "Hla i typing complete lr", "standard_charges": [ { "billing_class": "facility", "maximum": 1513.46, "minimum": 403.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 403.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1513.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1513.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81373", "type": "HCPCS" } ], "description": "Hla i typing 1 locus lr", "standard_charges": [ { "billing_class": "facility", "maximum": 477.86, "minimum": 127.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 127.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 477.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 477.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81374", "type": "HCPCS" } ], "description": "Hla i typing 1 antigen lr", "standard_charges": [ { "billing_class": "facility", "maximum": 278.74, "minimum": 74.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 74.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 278.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 278.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81375", "type": "HCPCS" } ], "description": "Hla ii typing ag equiv lr", "standard_charges": [ { "billing_class": "facility", "maximum": 827.78, "minimum": 220.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 220.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 827.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 827.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81376", "type": "HCPCS" } ], "description": "Hla ii typing 1 locus lr", "standard_charges": [ { "billing_class": "facility", "maximum": 458.33, "minimum": 122.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 458.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 458.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81377", "type": "HCPCS" } ], "description": "Hla ii type 1 ag equiv lr", "standard_charges": [ { "billing_class": "facility", "maximum": 355.28, "minimum": 94.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 355.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 355.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81378", "type": "HCPCS" } ], "description": "Hla i & ii typing hr", "standard_charges": [ { "billing_class": "facility", "maximum": 1295.89, "minimum": 345.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1295.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1295.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81379", "type": "HCPCS" } ], "description": "Hla i typing complete hr", "standard_charges": [ { "billing_class": "facility", "maximum": 1257.68, "minimum": 335.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 335.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1257.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1257.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81380", "type": "HCPCS" } ], "description": "Hla i typing 1 locus hr", "standard_charges": [ { "billing_class": "facility", "maximum": 664.69, "minimum": 177.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 177.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 664.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 664.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81381", "type": "HCPCS" } ], "description": "Hla i typing 1 allele hr", "standard_charges": [ { "billing_class": "facility", "maximum": 637.13, "minimum": 169.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 637.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 637.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81382", "type": "HCPCS" } ], "description": "Hla ii typing 1 loc hr", "standard_charges": [ { "billing_class": "facility", "maximum": 463.8, "minimum": 123.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 123.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 463.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 463.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81383", "type": "HCPCS" } ], "description": "Hla ii typing 1 allele hr", "standard_charges": [ { "billing_class": "facility", "maximum": 409.24, "minimum": 109.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 109.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 409.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 409.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81400", "type": "HCPCS" } ], "description": "Mopath procedure level 1", "standard_charges": [ { "billing_class": "facility", "maximum": 239.85, "minimum": 63.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 63.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 239.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 239.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81401", "type": "HCPCS" } ], "description": "Mopath procedure level 2", "standard_charges": [ { "billing_class": "facility", "maximum": 513.75, "minimum": 137.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 513.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 513.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81402", "type": "HCPCS" } ], "description": "Mopath procedure level 3", "standard_charges": [ { "billing_class": "facility", "maximum": 563.74, "minimum": 150.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 563.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 563.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81403", "type": "HCPCS" } ], "description": "Mopath procedure level 4", "standard_charges": [ { "billing_class": "facility", "maximum": 694.5, "minimum": 185.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 185.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 694.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 694.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81404", "type": "HCPCS" } ], "description": "Mopath procedure level 5", "standard_charges": [ { "billing_class": "facility", "maximum": 1030.61, "minimum": 274.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 274.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1030.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1030.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81405", "type": "HCPCS" } ], "description": "Mopath procedure level 6", "standard_charges": [ { "billing_class": "facility", "maximum": 1130.06, "minimum": 301.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 301.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1130.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1130.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81406", "type": "HCPCS" } ], "description": "Mopath procedure level 7", "standard_charges": [ { "billing_class": "facility", "maximum": 1060.8, "minimum": 282.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 282.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 1060.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 1060.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81407", "type": "HCPCS" } ], "description": "Mopath procedure level 8", "standard_charges": [ { "billing_class": "facility", "maximum": 3173.51, "minimum": 846.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 846.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3173.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3173.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82075", "type": "HCPCS" } ], "description": "Assay of breath ethanol", "standard_charges": [ { "billing_class": "facility", "maximum": 112.5, "minimum": 30.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82077", "type": "HCPCS" } ], "description": "Assay spec xcp ur&breath ia", "standard_charges": [ { "billing_class": "facility", "maximum": 64.76, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82085", "type": "HCPCS" } ], "description": "Assay of aldolase", "standard_charges": [ { "billing_class": "facility", "maximum": 36.41, "minimum": 9.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82088", "type": "HCPCS" } ], "description": "Assay of aldosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 152.81, "minimum": 40.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 152.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 152.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82103", "type": "HCPCS" } ], "description": "Alpha-1-antitrypsin total", "standard_charges": [ { "billing_class": "facility", "maximum": 50.4, "minimum": 13.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82104", "type": "HCPCS" } ], "description": "Alpha-1-antitrypsin pheno", "standard_charges": [ { "billing_class": "facility", "maximum": 54.23, "minimum": 14.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82105", "type": "HCPCS" } ], "description": "Alpha-fetoprotein serum", "standard_charges": [ { "billing_class": "facility", "maximum": 62.89, "minimum": 16.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82106", "type": "HCPCS" } ], "description": "Alpha-fetoprotein amniotic", "standard_charges": [ { "billing_class": "facility", "maximum": 63.75, "minimum": 17.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82107", "type": "HCPCS" } ], "description": "Alpha-Fetoprotein L3", "standard_charges": [ { "billing_class": "facility", "maximum": 241.54, "minimum": 64.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82108", "type": "HCPCS" } ], "description": "Assay of aluminum", "standard_charges": [ { "billing_class": "facility", "maximum": 95.55, "minimum": 25.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82120", "type": "HCPCS" } ], "description": "Amines vaginal fluid qual", "standard_charges": [ { "billing_class": "facility", "maximum": 22.46, "minimum": 5.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82127", "type": "HCPCS" } ], "description": "Amino acid single qual", "standard_charges": [ { "billing_class": "facility", "maximum": 53.18, "minimum": 14.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82128", "type": "HCPCS" } ], "description": "Amino acids mult qual", "standard_charges": [ { "billing_class": "facility", "maximum": 52.01, "minimum": 13.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82131", "type": "HCPCS" } ], "description": "Amino acids single quant", "standard_charges": [ { "billing_class": "facility", "maximum": 86.18, "minimum": 22.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82135", "type": "HCPCS" } ], "description": "Assay aminolevulinic acid", "standard_charges": [ { "billing_class": "facility", "maximum": 61.69, "minimum": 16.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82136", "type": "HCPCS" } ], "description": "Amino acids quant 2-5", "standard_charges": [ { "billing_class": "facility", "maximum": 73.54, "minimum": 19.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82139", "type": "HCPCS" } ], "description": "Amino acids quan 6 or more", "standard_charges": [ { "billing_class": "facility", "maximum": 63.26, "minimum": 16.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82140", "type": "HCPCS" } ], "description": "Assay of ammonia", "standard_charges": [ { "billing_class": "facility", "maximum": 54.64, "minimum": 14.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82143", "type": "HCPCS" } ], "description": "Amniotic fluid scan", "standard_charges": [ { "billing_class": "facility", "maximum": 35.06, "minimum": 9.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82150", "type": "HCPCS" } ], "description": "Assay of amylase", "standard_charges": [ { "billing_class": "facility", "maximum": 24.3, "minimum": 6.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82154", "type": "HCPCS" } ], "description": "Androstanediol glucuronide", "standard_charges": [ { "billing_class": "facility", "maximum": 108.11, "minimum": 28.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 108.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 108.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82157", "type": "HCPCS" } ], "description": "Assay of androstenedione", "standard_charges": [ { "billing_class": "facility", "maximum": 109.8, "minimum": 29.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 109.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82160", "type": "HCPCS" } ], "description": "Assay of androsterone", "standard_charges": [ { "billing_class": "facility", "maximum": 95.81, "minimum": 25.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82163", "type": "HCPCS" } ], "description": "Assay of angiotensin II", "standard_charges": [ { "billing_class": "facility", "maximum": 76.95, "minimum": 20.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82164", "type": "HCPCS" } ], "description": "Angiotensin I enzyme test", "standard_charges": [ { "billing_class": "facility", "maximum": 54.75, "minimum": 14.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82166", "type": "HCPCS" } ], "description": "Assay anti-mullerian horm", "standard_charges": [ { "billing_class": "facility", "maximum": 144.83, "minimum": 38.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82172", "type": "HCPCS" } ], "description": "Assay of apolipoprotein", "standard_charges": [ { "billing_class": "facility", "maximum": 79.09, "minimum": 21.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82175", "type": "HCPCS" } ], "description": "Assay of arsenic", "standard_charges": [ { "billing_class": "facility", "maximum": 71.14, "minimum": 18.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82180", "type": "HCPCS" } ], "description": "Assay of ascorbic acid", "standard_charges": [ { "billing_class": "facility", "maximum": 37.09, "minimum": 9.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82190", "type": "HCPCS" } ], "description": "Atomic absorption", "standard_charges": [ { "billing_class": "facility", "maximum": 59.63, "minimum": 15.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82232", "type": "HCPCS" } ], "description": "Assay of beta-2 protein", "standard_charges": [ { "billing_class": "facility", "maximum": 60.68, "minimum": 16.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82239", "type": "HCPCS" } ], "description": "Bile acids total", "standard_charges": [ { "billing_class": "facility", "maximum": 64.2, "minimum": 17.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82240", "type": "HCPCS" } ], "description": "Bile acids cholylglycine", "standard_charges": [ { "billing_class": "facility", "maximum": 99.68, "minimum": 26.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82247", "type": "HCPCS" } ], "description": "Bilirubin total", "standard_charges": [ { "billing_class": "facility", "maximum": 18.83, "minimum": 5.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82248", "type": "HCPCS" } ], "description": "Bilirubin direct", "standard_charges": [ { "billing_class": "facility", "maximum": 18.83, "minimum": 5.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82252", "type": "HCPCS" } ], "description": "Fecal bilirubin test", "standard_charges": [ { "billing_class": "facility", "maximum": 17.1, "minimum": 4.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82261", "type": "HCPCS" } ], "description": "Assay of biotinidase", "standard_charges": [ { "billing_class": "facility", "maximum": 63.26, "minimum": 16.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82270", "type": "HCPCS" } ], "description": "Occult blood feces", "standard_charges": [ { "billing_class": "facility", "maximum": 16.43, "minimum": 4.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82271", "type": "HCPCS" } ], "description": "Occult blood other sources", "standard_charges": [ { "billing_class": "facility", "maximum": 19.95, "minimum": 5.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82272", "type": "HCPCS" } ], "description": "Occult bld feces 1-3 tests", "standard_charges": [ { "billing_class": "facility", "maximum": 15.86, "minimum": 4.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82274", "type": "HCPCS" } ], "description": "Assay test for blood fecal", "standard_charges": [ { "billing_class": "facility", "maximum": 59.7, "minimum": 15.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82286", "type": "HCPCS" } ], "description": "Assay of bradykinin", "standard_charges": [ { "billing_class": "facility", "maximum": 19.35, "minimum": 5.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82300", "type": "HCPCS" } ], "description": "Assay of cadmium", "standard_charges": [ { "billing_class": "facility", "maximum": 88.65, "minimum": 23.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 88.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82306", "type": "HCPCS" } ], "description": "Vitamin d 25 hydroxy", "standard_charges": [ { "billing_class": "facility", "maximum": 111.0, "minimum": 29.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82308", "type": "HCPCS" } ], "description": "Assay of calcitonin", "standard_charges": [ { "billing_class": "facility", "maximum": 100.46, "minimum": 26.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82310", "type": "HCPCS" } ], "description": "Assay of calcium", "standard_charges": [ { "billing_class": "facility", "maximum": 19.35, "minimum": 5.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82330", "type": "HCPCS" } ], "description": "Assay of calcium", "standard_charges": [ { "billing_class": "facility", "maximum": 51.3, "minimum": 13.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82331", "type": "HCPCS" } ], "description": "Calcium infusion test", "standard_charges": [ { "billing_class": "facility", "maximum": 50.03, "minimum": 13.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82340", "type": "HCPCS" } ], "description": "Assay of calcium in urine", "standard_charges": [ { "billing_class": "facility", "maximum": 22.61, "minimum": 6.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82355", "type": "HCPCS" } ], "description": "Calculus analysis qual", "standard_charges": [ { "billing_class": "facility", "maximum": 43.43, "minimum": 11.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82360", "type": "HCPCS" } ], "description": "Calculus assay quant", "standard_charges": [ { "billing_class": "facility", "maximum": 48.26, "minimum": 12.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82365", "type": "HCPCS" } ], "description": "Calculus spectroscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 48.38, "minimum": 12.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82370", "type": "HCPCS" } ], "description": "X-ray assay calculus", "standard_charges": [ { "billing_class": "facility", "maximum": 46.95, "minimum": 12.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82373", "type": "HCPCS" } ], "description": "Assay c-d transfer measure", "standard_charges": [ { "billing_class": "facility", "maximum": 67.73, "minimum": 18.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82374", "type": "HCPCS" } ], "description": "Assay blood carbon dioxide", "standard_charges": [ { "billing_class": "facility", "maximum": 18.3, "minimum": 4.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82375", "type": "HCPCS" } ], "description": "Assay carboxyhb quant", "standard_charges": [ { "billing_class": "facility", "maximum": 46.2, "minimum": 12.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82376", "type": "HCPCS" } ], "description": "Assay carboxyhb qual", "standard_charges": [ { "billing_class": "facility", "maximum": 52.76, "minimum": 14.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82378", "type": "HCPCS" } ], "description": "Carcinoembryonic antigen", "standard_charges": [ { "billing_class": "facility", "maximum": 71.1, "minimum": 18.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82379", "type": "HCPCS" } ], "description": "Assay of carnitine", "standard_charges": [ { "billing_class": "facility", "maximum": 63.26, "minimum": 16.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82380", "type": "HCPCS" } ], "description": "Assay of carotene", "standard_charges": [ { "billing_class": "facility", "maximum": 34.58, "minimum": 9.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82382", "type": "HCPCS" } ], "description": "Assay urine catecholamines", "standard_charges": [ { "billing_class": "facility", "maximum": 102.38, "minimum": 27.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82383", "type": "HCPCS" } ], "description": "Assay blood catecholamines", "standard_charges": [ { "billing_class": "facility", "maximum": 109.05, "minimum": 29.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 109.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82384", "type": "HCPCS" } ], "description": "Assay three catecholamines", "standard_charges": [ { "billing_class": "facility", "maximum": 94.69, "minimum": 25.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82387", "type": "HCPCS" } ], "description": "Assay of cathepsin-d", "standard_charges": [ { "billing_class": "facility", "maximum": 67.73, "minimum": 18.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82390", "type": "HCPCS" } ], "description": "Assay of ceruloplasmin", "standard_charges": [ { "billing_class": "facility", "maximum": 40.28, "minimum": 10.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82397", "type": "HCPCS" } ], "description": "Chemiluminescent assay", "standard_charges": [ { "billing_class": "facility", "maximum": 52.95, "minimum": 14.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82415", "type": "HCPCS" } ], "description": "Assay of chloramphenicol", "standard_charges": [ { "billing_class": "facility", "maximum": 47.51, "minimum": 12.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82435", "type": "HCPCS" } ], "description": "Assay of blood chloride", "standard_charges": [ { "billing_class": "facility", "maximum": 17.25, "minimum": 4.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82436", "type": "HCPCS" } ], "description": "Assay of urine chloride", "standard_charges": [ { "billing_class": "facility", "maximum": 21.56, "minimum": 5.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82438", "type": "HCPCS" } ], "description": "Assay other fluid chlorides", "standard_charges": [ { "billing_class": "facility", "maximum": 18.75, "minimum": 5.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82441", "type": "HCPCS" } ], "description": "Test for chlorohydrocarbons", "standard_charges": [ { "billing_class": "facility", "maximum": 22.54, "minimum": 6.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82465", "type": "HCPCS" } ], "description": "Assay bld/serum cholesterol", "standard_charges": [ { "billing_class": "facility", "maximum": 16.31, "minimum": 4.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82480", "type": "HCPCS" } ], "description": "Assay serum cholinesterase", "standard_charges": [ { "billing_class": "facility", "maximum": 29.51, "minimum": 7.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82482", "type": "HCPCS" } ], "description": "Assay rbc cholinesterase", "standard_charges": [ { "billing_class": "facility", "maximum": 36.79, "minimum": 9.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82485", "type": "HCPCS" } ], "description": "Assay chondroitin sulfate", "standard_charges": [ { "billing_class": "facility", "maximum": 77.44, "minimum": 20.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82495", "type": "HCPCS" } ], "description": "Assay of chromium", "standard_charges": [ { "billing_class": "facility", "maximum": 76.05, "minimum": 20.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82507", "type": "HCPCS" } ], "description": "Assay of citrate", "standard_charges": [ { "billing_class": "facility", "maximum": 104.25, "minimum": 27.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 104.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82523", "type": "HCPCS" } ], "description": "Collagen crosslinks", "standard_charges": [ { "billing_class": "facility", "maximum": 70.05, "minimum": 18.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82525", "type": "HCPCS" } ], "description": "Assay of copper", "standard_charges": [ { "billing_class": "facility", "maximum": 46.54, "minimum": 12.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82528", "type": "HCPCS" } ], "description": "Assay of corticosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 84.45, "minimum": 22.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 84.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82530", "type": "HCPCS" } ], "description": "Cortisol free", "standard_charges": [ { "billing_class": "facility", "maximum": 62.66, "minimum": 16.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82533", "type": "HCPCS" } ], "description": "Total cortisol", "standard_charges": [ { "billing_class": "facility", "maximum": 61.13, "minimum": 16.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82540", "type": "HCPCS" } ], "description": "Assay of creatine", "standard_charges": [ { "billing_class": "facility", "maximum": 17.4, "minimum": 4.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82542", "type": "HCPCS" } ], "description": "Col chromotography qual/quan", "standard_charges": [ { "billing_class": "facility", "maximum": 90.34, "minimum": 24.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82550", "type": "HCPCS" } ], "description": "Assay of ck (cpk)", "standard_charges": [ { "billing_class": "facility", "maximum": 24.41, "minimum": 6.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82552", "type": "HCPCS" } ], "description": "Assay of cpk in blood", "standard_charges": [ { "billing_class": "facility", "maximum": 50.21, "minimum": 13.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82553", "type": "HCPCS" } ], "description": "Creatine mb fraction", "standard_charges": [ { "billing_class": "facility", "maximum": 43.31, "minimum": 11.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82554", "type": "HCPCS" } ], "description": "Creatine isoforms", "standard_charges": [ { "billing_class": "facility", "maximum": 44.51, "minimum": 11.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82565", "type": "HCPCS" } ], "description": "Assay of creatinine", "standard_charges": [ { "billing_class": "facility", "maximum": 19.2, "minimum": 5.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82570", "type": "HCPCS" } ], "description": "Assay of urine creatinine", "standard_charges": [ { "billing_class": "facility", "maximum": 19.43, "minimum": 5.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82575", "type": "HCPCS" } ], "description": "Creatinine clearance test", "standard_charges": [ { "billing_class": "facility", "maximum": 35.48, "minimum": 9.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82585", "type": "HCPCS" } ], "description": "Assay of cryofibrinogen", "standard_charges": [ { "billing_class": "facility", "maximum": 53.03, "minimum": 14.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82595", "type": "HCPCS" } ], "description": "Assay of cryoglobulin", "standard_charges": [ { "billing_class": "facility", "maximum": 24.26, "minimum": 6.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82600", "type": "HCPCS" } ], "description": "Assay of cyanide", "standard_charges": [ { "billing_class": "facility", "maximum": 72.75, "minimum": 19.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82607", "type": "HCPCS" } ], "description": "Vitamin B-12", "standard_charges": [ { "billing_class": "facility", "maximum": 56.55, "minimum": 15.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82608", "type": "HCPCS" } ], "description": "B-12 binding capacity", "standard_charges": [ { "billing_class": "facility", "maximum": 53.7, "minimum": 14.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82610", "type": "HCPCS" } ], "description": "Cystatin c", "standard_charges": [ { "billing_class": "facility", "maximum": 69.45, "minimum": 18.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82615", "type": "HCPCS" } ], "description": "Test for urine cystines", "standard_charges": [ { "billing_class": "facility", "maximum": 35.81, "minimum": 9.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82626", "type": "HCPCS" } ], "description": "Dehydroepiandrosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 94.76, "minimum": 25.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82627", "type": "HCPCS" } ], "description": "Dehydroepiandrosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 83.36, "minimum": 22.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82633", "type": "HCPCS" } ], "description": "Desoxycorticosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 116.18, "minimum": 30.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 116.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 116.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82634", "type": "HCPCS" } ], "description": "Deoxycortisol", "standard_charges": [ { "billing_class": "facility", "maximum": 109.8, "minimum": 29.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 109.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82638", "type": "HCPCS" } ], "description": "Assay of dibucaine number", "standard_charges": [ { "billing_class": "facility", "maximum": 45.94, "minimum": 12.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82642", "type": "HCPCS" } ], "description": "Dihydrotestosterone", "standard_charges": [ { "billing_class": "facility", "maximum": 109.8, "minimum": 29.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 109.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82652", "type": "HCPCS" } ], "description": "Vit d 1 25-dihydroxy", "standard_charges": [ { "billing_class": "facility", "maximum": 144.38, "minimum": 38.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 144.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82653", "type": "HCPCS" } ], "description": "El-1 fecal quantitative", "standard_charges": [ { "billing_class": "facility", "maximum": 86.14, "minimum": 22.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82656", "type": "HCPCS" } ], "description": "Pancreatic elastase fecal", "standard_charges": [ { "billing_class": "facility", "maximum": 43.24, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82657", "type": "HCPCS" } ], "description": "Enzyme cell activity", "standard_charges": [ { "billing_class": "facility", "maximum": 83.14, "minimum": 22.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82658", "type": "HCPCS" } ], "description": "Enzyme cell activity ra", "standard_charges": [ { "billing_class": "facility", "maximum": 165.11, "minimum": 44.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 165.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 165.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82664", "type": "HCPCS" } ], "description": "Electrophoretic test", "standard_charges": [ { "billing_class": "facility", "maximum": 230.63, "minimum": 61.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 230.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 230.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82668", "type": "HCPCS" } ], "description": "Assay of erythropoietin", "standard_charges": [ { "billing_class": "facility", "maximum": 70.46, "minimum": 18.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82670", "type": "HCPCS" } ], "description": "Assay of estradiol", "standard_charges": [ { "billing_class": "facility", "maximum": 104.78, "minimum": 27.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 104.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82671", "type": "HCPCS" } ], "description": "Assay of estrogens", "standard_charges": [ { "billing_class": "facility", "maximum": 121.13, "minimum": 32.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 121.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 121.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82672", "type": "HCPCS" } ], "description": "Assay of estrogen", "standard_charges": [ { "billing_class": "facility", "maximum": 81.38, "minimum": 21.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82677", "type": "HCPCS" } ], "description": "Assay of estriol", "standard_charges": [ { "billing_class": "facility", "maximum": 90.68, "minimum": 24.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82679", "type": "HCPCS" } ], "description": "Assay of estrone", "standard_charges": [ { "billing_class": "facility", "maximum": 93.56, "minimum": 24.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82681", "type": "HCPCS" } ], "description": "Assay dir meas fr estradiol", "standard_charges": [ { "billing_class": "facility", "maximum": 104.78, "minimum": 27.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 104.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84182", "type": "HCPCS" } ], "description": "Protein western blot test", "standard_charges": [ { "billing_class": "facility", "maximum": 109.54, "minimum": 29.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 109.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84202", "type": "HCPCS" } ], "description": "Assay RBC protoporphyrin", "standard_charges": [ { "billing_class": "facility", "maximum": 53.81, "minimum": 14.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84203", "type": "HCPCS" } ], "description": "Test RBC protoporphyrin", "standard_charges": [ { "billing_class": "facility", "maximum": 36.53, "minimum": 9.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84206", "type": "HCPCS" } ], "description": "Assay of proinsulin", "standard_charges": [ { "billing_class": "facility", "maximum": 100.09, "minimum": 26.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84207", "type": "HCPCS" } ], "description": "Assay of vitamin b-6", "standard_charges": [ { "billing_class": "facility", "maximum": 105.38, "minimum": 28.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 105.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 105.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84210", "type": "HCPCS" } ], "description": "Assay of pyruvate", "standard_charges": [ { "billing_class": "facility", "maximum": 54.3, "minimum": 14.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84220", "type": "HCPCS" } ], "description": "Assay of pyruvate kinase", "standard_charges": [ { "billing_class": "facility", "maximum": 35.4, "minimum": 9.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84228", "type": "HCPCS" } ], "description": "Assay of quinine", "standard_charges": [ { "billing_class": "facility", "maximum": 43.61, "minimum": 11.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84233", "type": "HCPCS" } ], "description": "Assay of estrogen", "standard_charges": [ { "billing_class": "facility", "maximum": 329.55, "minimum": 87.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 87.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 329.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 329.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84234", "type": "HCPCS" } ], "description": "Assay of progesterone", "standard_charges": [ { "billing_class": "facility", "maximum": 243.3, "minimum": 64.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 243.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 243.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84235", "type": "HCPCS" } ], "description": "Assay of endocrine hormone", "standard_charges": [ { "billing_class": "facility", "maximum": 267.11, "minimum": 71.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 267.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 267.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84238", "type": "HCPCS" } ], "description": "Assay nonendocrine receptor", "standard_charges": [ { "billing_class": "facility", "maximum": 137.14, "minimum": 36.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 137.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 137.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84244", "type": "HCPCS" } ], "description": "Assay of renin", "standard_charges": [ { "billing_class": "facility", "maximum": 82.46, "minimum": 21.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84252", "type": "HCPCS" } ], "description": "Assay of vitamin b-2", "standard_charges": [ { "billing_class": "facility", "maximum": 75.9, "minimum": 20.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84255", "type": "HCPCS" } ], "description": "Assay of selenium", "standard_charges": [ { "billing_class": "facility", "maximum": 95.74, "minimum": 25.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84260", "type": "HCPCS" } ], "description": "Assay of serotonin", "standard_charges": [ { "billing_class": "facility", "maximum": 116.18, "minimum": 30.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 116.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 116.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43213", "type": "HCPCS" } ], "description": "Esophagoscopy retro balloon", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43214", "type": "HCPCS" } ], "description": "Esophagosc dilate balloon 30", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43215", "type": "HCPCS" } ], "description": "Esophagoscopy flex remove fb", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43216", "type": "HCPCS" } ], "description": "Esophagoscopy lesion removal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43217", "type": "HCPCS" } ], "description": "Esophagoscopy snare les remv", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43220", "type": "HCPCS" } ], "description": "Esophagoscopy balloon <30mm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43226", "type": "HCPCS" } ], "description": "Esoph endoscopy dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43227", "type": "HCPCS" } ], "description": "Esophagoscopy control bleed", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43229", "type": "HCPCS" } ], "description": "Esophagoscopy lesion ablate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43231", "type": "HCPCS" } ], "description": "Esophagoscop ultrasound exam", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43232", "type": "HCPCS" } ], "description": "Esophagoscopy w/us needle bx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43233", "type": "HCPCS" } ], "description": "Egd balloon dil esoph30 mm/>", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43235", "type": "HCPCS" } ], "description": "Egd diagnostic brush wash", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43236", "type": "HCPCS" } ], "description": "Uppr gi scope w/submuc inj", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43237", "type": "HCPCS" } ], "description": "Endoscopic us exam esoph", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43238", "type": "HCPCS" } ], "description": "Egd us fine needle bx/aspir", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43239", "type": "HCPCS" } ], "description": "Egd biopsy single/multiple", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43240", "type": "HCPCS" } ], "description": "Egd w/transmural drain cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43241", "type": "HCPCS" } ], "description": "Egd tube/cath insertion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43242", "type": "HCPCS" } ], "description": "Egd us fine needle bx/aspir", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43243", "type": "HCPCS" } ], "description": "Egd injection varices", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43244", "type": "HCPCS" } ], "description": "Egd varices ligation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43245", "type": "HCPCS" } ], "description": "Egd dilate stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43246", "type": "HCPCS" } ], "description": "Egd place gastrostomy tube", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43247", "type": "HCPCS" } ], "description": "Egd remove foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43248", "type": "HCPCS" } ], "description": "Egd guide wire insertion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43249", "type": "HCPCS" } ], "description": "Esoph egd dilation <30 mm", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43250", "type": "HCPCS" } ], "description": "Egd cautery tumor polyp", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43251", "type": "HCPCS" } ], "description": "Egd remove lesion snare", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43252", "type": "HCPCS" } ], "description": "Egd optical endomicroscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43253", "type": "HCPCS" } ], "description": "Egd us transmural injxn/mark", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43254", "type": "HCPCS" } ], "description": "Egd endo mucosal resection", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43255", "type": "HCPCS" } ], "description": "Egd control bleeding any", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43257", "type": "HCPCS" } ], "description": "Egd w/thrml txmnt gerd", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43259", "type": "HCPCS" } ], "description": "Egd us exam duodenum/jejunum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43260", "type": "HCPCS" } ], "description": "Ercp w/specimen collection", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43261", "type": "HCPCS" } ], "description": "Endo cholangiopancreatograph", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43262", "type": "HCPCS" } ], "description": "Endo cholangiopancreatograph", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43263", "type": "HCPCS" } ], "description": "Ercp sphincter pressure meas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43264", "type": "HCPCS" } ], "description": "Ercp remove duct calculi", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43265", "type": "HCPCS" } ], "description": "Ercp lithotripsy calculi", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43266", "type": "HCPCS" } ], "description": "Egd endoscopic stent place", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43270", "type": "HCPCS" } ], "description": "Egd lesion ablation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43274", "type": "HCPCS" } ], "description": "Ercp duct stent placement", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43275", "type": "HCPCS" } ], "description": "Ercp remove forgn body duct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43276", "type": "HCPCS" } ], "description": "Ercp stent exchange w/dilate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43277", "type": "HCPCS" } ], "description": "Ercp ea duct/ampulla dilate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43278", "type": "HCPCS" } ], "description": "Ercp lesion ablate w/dilate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43279", "type": "HCPCS" } ], "description": "Lap myotomy heller", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43280", "type": "HCPCS" } ], "description": "Laparoscopy fundoplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43281", "type": "HCPCS" } ], "description": "Lap paraesophag hern repair", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43282", "type": "HCPCS" } ], "description": "Lap paraesoph her rpr w/mesh", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43283", "type": "HCPCS" } ], "description": "Lap esoph lengthening", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 38216.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43284", "type": "HCPCS" } ], "description": "Laps esophgl sphnctr agmntj", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43285", "type": "HCPCS" } ], "description": "Rmvl esophgl sphnctr dev", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43286", "type": "HCPCS" } ], "description": "Esphg tot w/laps moblj", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43287", "type": "HCPCS" } ], "description": "Esphg dstl 2/3 w/laps moblj", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43288", "type": "HCPCS" } ], "description": "Esphg thrsc moblj", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43289", "type": "HCPCS" } ], "description": "Laparoscope proc esoph", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43290", "type": "HCPCS" } ], "description": "Egd flx trnsorl dplmnt balo", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43291", "type": "HCPCS" } ], "description": "Egd flx trnsorl rmvl balo", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43300", "type": "HCPCS" } ], "description": "Repair of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43305", "type": "HCPCS" } ], "description": "Repair esophagus and fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43310", "type": "HCPCS" } ], "description": "Repair of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43312", "type": "HCPCS" } ], "description": "Repair esophagus and fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43313", "type": "HCPCS" } ], "description": "Esophagoplasty congenital", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43314", "type": "HCPCS" } ], "description": "Tracheo-esophagoplasty cong", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43320", "type": "HCPCS" } ], "description": "Fuse esophagus & stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43325", "type": "HCPCS" } ], "description": "Revise esophagus & stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43327", "type": "HCPCS" } ], "description": "Esoph fundoplasty lap", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43328", "type": "HCPCS" } ], "description": "Esoph fundoplasty thor", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43330", "type": "HCPCS" } ], "description": "Esophagomyotomy abdominal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43331", "type": "HCPCS" } ], "description": "Esophagomyotomy thoracic", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43332", "type": "HCPCS" } ], "description": "Transab esoph hiat hern rpr", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43333", "type": "HCPCS" } ], "description": "Transab esoph hiat hern rpr", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43334", "type": "HCPCS" } ], "description": "Transthor diaphrag hern rpr", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43335", "type": "HCPCS" } ], "description": "Transthor diaphrag hern rpr", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43336", "type": "HCPCS" } ], "description": "Thorabd diaphr hern repair", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43337", "type": "HCPCS" } ], "description": "Thorabd diaphr hern repair", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43338", "type": "HCPCS" } ], "description": "Esoph lengthening", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43340", "type": "HCPCS" } ], "description": "Fuse esophagus & intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43341", "type": "HCPCS" } ], "description": "Fuse esophagus & intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43351", "type": "HCPCS" } ], "description": "Surgical opening esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43352", "type": "HCPCS" } ], "description": "Surgical opening esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43360", "type": "HCPCS" } ], "description": "Gastrointestinal repair", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43361", "type": "HCPCS" } ], "description": "Gastrointestinal repair", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43400", "type": "HCPCS" } ], "description": "Ligate esophagus veins", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43405", "type": "HCPCS" } ], "description": "Ligate/staple esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43410", "type": "HCPCS" } ], "description": "Repair esophagus wound", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43415", "type": "HCPCS" } ], "description": "Repair esophagus wound", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43420", "type": "HCPCS" } ], "description": "Repair esophagus opening", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43425", "type": "HCPCS" } ], "description": "Repair esophagus opening", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43450", "type": "HCPCS" } ], "description": "Dilate esophagus 1/mult pass", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43453", "type": "HCPCS" } ], "description": "Dilate esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43460", "type": "HCPCS" } ], "description": "Pressure treatment esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43496", "type": "HCPCS" } ], "description": "Free jejunum flap microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43497", "type": "HCPCS" } ], "description": "Transorl lwr esophgl myotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43499", "type": "HCPCS" } ], "description": "Esophagus surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43500", "type": "HCPCS" } ], "description": "Surgical opening of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43501", "type": "HCPCS" } ], "description": "Surgical repair of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43502", "type": "HCPCS" } ], "description": "Surgical repair of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43510", "type": "HCPCS" } ], "description": "Surgical opening of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43520", "type": "HCPCS" } ], "description": "Incision of pyloric muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43605", "type": "HCPCS" } ], "description": "Biopsy of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43610", "type": "HCPCS" } ], "description": "Excision of stomach lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43611", "type": "HCPCS" } ], "description": "Excision of stomach lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43620", "type": "HCPCS" } ], "description": "Removal of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43621", "type": "HCPCS" } ], "description": "Removal of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43622", "type": "HCPCS" } ], "description": "Removal of stomach", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43631", "type": "HCPCS" } ], "description": "Removal of stomach partial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43632", "type": "HCPCS" } ], "description": "Removal of stomach partial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43633", "type": "HCPCS" } ], "description": "Removal of stomach partial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43634", "type": "HCPCS" } ], "description": "Removal of stomach partial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43635", "type": "HCPCS" } ], "description": "Removal of stomach partial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43640", "type": "HCPCS" } ], "description": "Vagotomy & pylorus repair", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43641", "type": "HCPCS" } ], "description": "Vagotomy & pylorus repair", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43644", "type": "HCPCS" } ], "description": "Lap gastric bypass/roux-en-y", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43645", "type": "HCPCS" } ], "description": "Lap gastr bypass incl smll i", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43647", "type": "HCPCS" } ], "description": "Lap impl electrode antrum", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43648", "type": "HCPCS" } ], "description": "Lap revise/remv eltrd antrum", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43651", "type": "HCPCS" } ], "description": "Laparoscopy vagus nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43652", "type": "HCPCS" } ], "description": "Laparoscopy vagus nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43653", "type": "HCPCS" } ], "description": "Laparoscopy gastrostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43659", "type": "HCPCS" } ], "description": "Laparoscope proc stom", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43752", "type": "HCPCS" } ], "description": "Nasal/orogastric w/tube plmt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43753", "type": "HCPCS" } ], "description": "Tx gastro intub w/asp", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43754", "type": "HCPCS" } ], "description": "Dx gastr intub w/asp spec", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43755", "type": "HCPCS" } ], "description": "Dx gastr intub w/asp specs", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43756", "type": "HCPCS" } ], "description": "Dx duod intub w/asp spec", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43757", "type": "HCPCS" } ], "description": "Dx duod intub w/asp specs", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43761", "type": "HCPCS" } ], "description": "Reposition gastrostomy tube", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43762", "type": "HCPCS" } ], "description": "Rplc gtube no revj trc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43763", "type": "HCPCS" } ], "description": "Rplc gtube revj gstrst trc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43770", "type": "HCPCS" } ], "description": "Lap place gastr adj device", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43771", "type": "HCPCS" } ], "description": "Lap revise gastr adj device", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43772", "type": "HCPCS" } ], "description": "Lap rmvl gastr adj device", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43773", "type": "HCPCS" } ], "description": "Lap replace gastr adj device", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43774", "type": "HCPCS" } ], "description": "Lap rmvl gastr adj all parts", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43775", "type": "HCPCS" } ], "description": "Lap sleeve gastrectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43800", "type": "HCPCS" } ], "description": "Reconstruction of pylorus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43810", "type": "HCPCS" } ], "description": "Fusion of stomach and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43820", "type": "HCPCS" } ], "description": "Fusion of stomach and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43825", "type": "HCPCS" } ], "description": "Fusion of stomach and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43830", "type": "HCPCS" } ], "description": "Place gastrostomy tube", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43831", "type": "HCPCS" } ], "description": "Place gastrostomy tube", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43832", "type": "HCPCS" } ], "description": "Place gastrostomy tube", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43840", "type": "HCPCS" } ], "description": "Repair of stomach lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43842", "type": "HCPCS" } ], "description": "V-band gastroplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43843", "type": "HCPCS" } ], "description": "Gastroplasty w/o v-band", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43845", "type": "HCPCS" } ], "description": "Gastroplasty duodenal switch", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43846", "type": "HCPCS" } ], "description": "Gastric bypass for obesity", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43847", "type": "HCPCS" } ], "description": "Gastric bypass incl small i", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43848", "type": "HCPCS" } ], "description": "Revision gastroplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43860", "type": "HCPCS" } ], "description": "Revise stomach-bowel fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43865", "type": "HCPCS" } ], "description": "Revise stomach-bowel fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43870", "type": "HCPCS" } ], "description": "Repair stomach opening", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43880", "type": "HCPCS" } ], "description": "Repair stomach-bowel fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43881", "type": "HCPCS" } ], "description": "Impl/redo electrd antrum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43882", "type": "HCPCS" } ], "description": "Revise/remove electrd antrum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43886", "type": "HCPCS" } ], "description": "Revise gastric port open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43887", "type": "HCPCS" } ], "description": "Remove gastric port open", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43888", "type": "HCPCS" } ], "description": "Change gastric port open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43999", "type": "HCPCS" } ], "description": "Stomach surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44005", "type": "HCPCS" } ], "description": "Freeing of bowel adhesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44010", "type": "HCPCS" } ], "description": "Incision of small bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44015", "type": "HCPCS" } ], "description": "Insert needle cath bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44020", "type": "HCPCS" } ], "description": "Explore small intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44021", "type": "HCPCS" } ], "description": "Decompress small bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44025", "type": "HCPCS" } ], "description": "Incision of large bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44050", "type": "HCPCS" } ], "description": "Reduce bowel obstruction", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44055", "type": "HCPCS" } ], "description": "Correct malrotation of bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44100", "type": "HCPCS" } ], "description": "Biopsy of bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44110", "type": "HCPCS" } ], "description": "Excise intestine lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44111", "type": "HCPCS" } ], "description": "Excision of bowel lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44120", "type": "HCPCS" } ], "description": "Removal of small intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44121", "type": "HCPCS" } ], "description": "Removal of small intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44125", "type": "HCPCS" } ], "description": "Removal of small intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44126", "type": "HCPCS" } ], "description": "Enterectomy w/o taper cong", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44127", "type": "HCPCS" } ], "description": "Enterectomy w/taper cong", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44128", "type": "HCPCS" } ], "description": "Enterectomy cong add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44130", "type": "HCPCS" } ], "description": "Bowel to bowel fusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44132", "type": "HCPCS" } ], "description": "Enterectomy cadaver donor", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44133", "type": "HCPCS" } ], "description": "Enterectomy live donor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44135", "type": "HCPCS" } ], "description": "Intestine transplnt cadaver", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44136", "type": "HCPCS" } ], "description": "Intestine transplant live", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44137", "type": "HCPCS" } ], "description": "Remove intestinal allograft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44139", "type": "HCPCS" } ], "description": "Mobilization of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44140", "type": "HCPCS" } ], "description": "Partial removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44141", "type": "HCPCS" } ], "description": "Partial removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44143", "type": "HCPCS" } ], "description": "Partial removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44144", "type": "HCPCS" } ], "description": "Partial removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44145", "type": "HCPCS" } ], "description": "Partial removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44146", "type": "HCPCS" } ], "description": "Partial removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44147", "type": "HCPCS" } ], "description": "Partial removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44150", "type": "HCPCS" } ], "description": "Removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44151", "type": "HCPCS" } ], "description": "Removal of colon/ileostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44155", "type": "HCPCS" } ], "description": "Removal of colon/ileostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44156", "type": "HCPCS" } ], "description": "Removal of colon/ileostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44157", "type": "HCPCS" } ], "description": "Colectomy w/Ileoanal Anast", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44158", "type": "HCPCS" } ], "description": "Colectomy w/Neo-Rectum Pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44160", "type": "HCPCS" } ], "description": "Removal of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44180", "type": "HCPCS" } ], "description": "Lap enterolysis", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44186", "type": "HCPCS" } ], "description": "Lap jejunostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44187", "type": "HCPCS" } ], "description": "Lap ileo/jejuno-stomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44188", "type": "HCPCS" } ], "description": "Lap colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44202", "type": "HCPCS" } ], "description": "Lap enterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44203", "type": "HCPCS" } ], "description": "Lap resect s/intestine addl", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44204", "type": "HCPCS" } ], "description": "Laparo partial colectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44205", "type": "HCPCS" } ], "description": "Lap colectomy part w/ileum", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44206", "type": "HCPCS" } ], "description": "Lap part colectomy w/stoma", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44207", "type": "HCPCS" } ], "description": "L colectomy/coloproctostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44208", "type": "HCPCS" } ], "description": "L colectomy/coloproctostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44210", "type": "HCPCS" } ], "description": "Laparo total proctocolectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44211", "type": "HCPCS" } ], "description": "Lap colectomy w/proctectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44212", "type": "HCPCS" } ], "description": "Laparo total proctocolectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44213", "type": "HCPCS" } ], "description": "Lap mobil splenic fl add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44227", "type": "HCPCS" } ], "description": "Lap close enterostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44238", "type": "HCPCS" } ], "description": "Laparoscope proc intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44300", "type": "HCPCS" } ], "description": "Open bowel to skin", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44310", "type": "HCPCS" } ], "description": "Ileostomy/jejunostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44312", "type": "HCPCS" } ], "description": "Revision of ileostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44314", "type": "HCPCS" } ], "description": "Revision of ileostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44316", "type": "HCPCS" } ], "description": "Devise bowel pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44320", "type": "HCPCS" } ], "description": "Colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44322", "type": "HCPCS" } ], "description": "Colostomy with biopsies", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44340", "type": "HCPCS" } ], "description": "Revision of colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44345", "type": "HCPCS" } ], "description": "Revision of colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44346", "type": "HCPCS" } ], "description": "Revision of colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3416.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3416.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44360", "type": "HCPCS" } ], "description": "Small bowel endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44361", "type": "HCPCS" } ], "description": "Small bowel endoscopy/biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44363", "type": "HCPCS" } ], "description": "Small bowel endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44364", "type": "HCPCS" } ], "description": "Small bowel endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44365", "type": "HCPCS" } ], "description": "Small bowel endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44366", "type": "HCPCS" } ], "description": "Small bowel endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44369", "type": "HCPCS" } ], "description": "Small bowel endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44370", "type": "HCPCS" } ], "description": "Small Bowel Endoscopy/Stent", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5853.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5853.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44372", "type": "HCPCS" } ], "description": "Small bowel endoscopy", "standard_charges": [ { "billing_class": 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"standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44403", "type": "HCPCS" } ], "description": "Colonoscopy w/resection", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44404", "type": "HCPCS" } ], "description": "Colonoscopy w/injection", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44405", "type": "HCPCS" } ], "description": "Colonoscopy w/dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44406", "type": "HCPCS" } ], "description": "Colonoscopy w/ultrasound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { 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w/decompression", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44500", "type": "HCPCS" } ], "description": "Intro gastrointestinal tube", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44602", "type": "HCPCS" } ], "description": "Suture small intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44603", "type": "HCPCS" } ], "description": "Suture small intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { 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schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44660", "type": "HCPCS" } ], "description": "Repair bowel-bladder fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44661", "type": "HCPCS" } ], "description": "Repair bowel-bladder fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44680", "type": "HCPCS" } ], "description": "Surgical revision intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44700", "type": "HCPCS" } ], "description": "Suspend bowel w/prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44705", "type": "HCPCS" } ], "description": "Prepare fecal microbiota", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44715", "type": "HCPCS" } ], "description": "Prepare donor intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44720", "type": "HCPCS" } ], "description": "Prep donor intestine/venous", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44721", "type": "HCPCS" } ], "description": "Prep donor intestine/artery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44799", "type": "HCPCS" } ], "description": "Unlisted px small intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44800", "type": "HCPCS" } ], "description": "Excision of bowel pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44820", "type": "HCPCS" } ], "description": "Excision of mesentery lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44850", "type": "HCPCS" } ], "description": "Repair of mesentery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44899", "type": "HCPCS" } ], "description": "Bowel surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 16564.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44900", "type": "HCPCS" } ], "description": "Drain appendix abscess open", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44950", "type": "HCPCS" } ], "description": "Appendectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44960", "type": "HCPCS" } ], "description": "Appendectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44970", "type": "HCPCS" } ], "description": "Laparoscopy appendectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "44979", "type": "HCPCS" } ], "description": "Laparoscope proc app", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45000", "type": "HCPCS" } ], "description": "Drainage of pelvic abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45005", "type": "HCPCS" } ], "description": "Drainage of rectal abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45020", "type": "HCPCS" } ], "description": "Drainage of rectal abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45100", "type": "HCPCS" } ], "description": "Biopsy of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45108", "type": "HCPCS" } ], "description": "Removal of anorectal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45110", "type": "HCPCS" } ], "description": "Removal of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45111", "type": "HCPCS" } ], "description": "Partial removal of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45112", "type": "HCPCS" } ], "description": "Removal of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45113", "type": "HCPCS" } ], "description": "Partial proctectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45114", "type": "HCPCS" } ], "description": "Partial removal of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45116", "type": "HCPCS" } ], "description": "Partial removal of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45119", "type": "HCPCS" } ], "description": "Remove rectum w/reservoir", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45120", "type": "HCPCS" } ], "description": "Removal of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45121", "type": "HCPCS" } ], "description": "Removal of rectum and colon", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45123", "type": "HCPCS" } ], "description": "Partial proctectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45126", "type": "HCPCS" } ], "description": "Pelvic exenteration", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45130", "type": "HCPCS" } ], "description": "Excision of rectal prolapse", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45135", "type": "HCPCS" } ], "description": "Excision of rectal prolapse", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45136", "type": "HCPCS" } ], "description": "Excise ileoanal reservior", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45150", "type": "HCPCS" } ], "description": "Excision of rectal stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45160", "type": "HCPCS" } ], "description": "Excision of rectal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45171", "type": "HCPCS" } ], "description": "Exc rect tum transanal part", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45172", "type": "HCPCS" } ], "description": "Exc rect tum transanal full", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45190", "type": "HCPCS" } ], "description": "Destruction rectal tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45300", "type": "HCPCS" } ], "description": "Proctosigmoidoscopy dx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45303", "type": "HCPCS" } ], "description": "Proctosigmoidoscopy dilate", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45305", "type": "HCPCS" } ], "description": "Proctosigmoidoscopy w/bx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45307", "type": "HCPCS" } ], "description": "Proctosigmoidoscopy fb", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", 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"description": "Lap remove rectum w/pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45398", "type": "HCPCS" } ], "description": "Colonoscopy w/band ligation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45399", "type": "HCPCS" } ], "description": "Unlisted procedure colon", 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"maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45499", "type": "HCPCS" } ], "description": "Laparoscope proc rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45500", "type": "HCPCS" } ], "description": "Repair of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45505", "type": "HCPCS" } ], "description": "Repair of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45520", "type": "HCPCS" } ], "description": "Treatment of rectal prolapse", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45540", "type": "HCPCS" } ], "description": "Correct rectal prolapse", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45541", "type": "HCPCS" } ], "description": "Correct rectal prolapse", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45550", "type": "HCPCS" } ], "description": "Repair rectum/remove sigmoid", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45560", "type": "HCPCS" } ], "description": "Repair of rectocele", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45562", "type": "HCPCS" } ], "description": "Exploration/repair of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45563", "type": "HCPCS" } ], "description": "Exploration/repair of rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45800", "type": "HCPCS" } ], "description": "Repair rect/bladder fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45805", "type": "HCPCS" } ], "description": "Repair fistula w/colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45820", "type": "HCPCS" } ], "description": "Repair rectourethral fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45825", "type": "HCPCS" } ], "description": "Repair fistula w/colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45900", "type": "HCPCS" } ], "description": "Reduction of rectal prolapse", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45905", "type": "HCPCS" } ], "description": "Dilation of anal sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45910", "type": "HCPCS" } ], "description": "Dilation of rectal narrowing", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45915", "type": "HCPCS" } ], "description": "Remove rectal obstruction", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45990", "type": "HCPCS" } ], "description": "Surg dx exam anorectal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "45999", "type": "HCPCS" } ], "description": "Rectum surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46020", "type": "HCPCS" } ], "description": "Placement of seton", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46030", "type": "HCPCS" } ], "description": "Removal of rectal marker", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46040", "type": "HCPCS" } ], "description": "Incision of rectal abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46045", "type": "HCPCS" } ], "description": "Incision of rectal abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46050", "type": "HCPCS" } ], "description": "Incision of anal abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46060", "type": "HCPCS" } ], "description": "Incision of rectal abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46070", "type": "HCPCS" } ], "description": "Incision of anal septum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46080", "type": "HCPCS" } ], "description": "Incision of anal sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46083", "type": "HCPCS" } ], "description": "Incise external hemorrhoid", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46200", "type": "HCPCS" } ], "description": "Removal of anal fissure", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46220", "type": "HCPCS" } ], "description": "Excise anal ext tag/papilla", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46221", "type": "HCPCS" } ], "description": "Ligation of hemorrhoid(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46230", "type": "HCPCS" } ], "description": "Removal of anal tags", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46250", "type": "HCPCS" } ], "description": "Remove ext hem groups 2+", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46255", "type": "HCPCS" } ], "description": "Remove int/ext hem 1 group", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46257", "type": "HCPCS" } ], "description": "Remove in/ex hem grp & fiss", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46258", "type": "HCPCS" } ], "description": "Remove in/ex hem grp w/fistu", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46260", "type": "HCPCS" } ], "description": "Remove in/ex hem groups 2+", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46261", "type": "HCPCS" } ], "description": "Remove in/ex hem grps & fiss", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46262", "type": "HCPCS" } ], "description": "Remove in/ex hem grps w/fist", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46270", "type": "HCPCS" } ], "description": "Remove anal fist subq", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46275", "type": "HCPCS" } ], "description": "Remove anal fist inter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46280", "type": "HCPCS" } ], "description": "Remove anal fist complex", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46285", "type": "HCPCS" } ], "description": "Remove anal fist 2 stage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46288", "type": "HCPCS" } ], "description": "Repair anal fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46320", "type": "HCPCS" } ], "description": "Removal of hemorrhoid clot", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46500", "type": "HCPCS" } ], "description": "Injection into hemorrhoid(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46505", "type": "HCPCS" } ], "description": "Chemodenervation anal musc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46600", "type": "HCPCS" } ], "description": "Diagnostic anoscopy spx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46601", "type": "HCPCS" } ], "description": "Diagnostic anoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46604", "type": "HCPCS" } ], "description": "Anoscopy and dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46606", "type": "HCPCS" } ], "description": "Anoscopy and biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46607", "type": "HCPCS" } ], "description": "Diagnostic anoscopy & biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46608", "type": "HCPCS" } ], "description": "Anoscopy remove for body", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46610", "type": "HCPCS" } ], "description": "Anoscopy remove lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46611", "type": "HCPCS" } ], "description": "Anoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46612", "type": "HCPCS" } ], "description": "Anoscopy remove lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46614", "type": "HCPCS" } ], "description": "Anoscopy control bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46615", "type": "HCPCS" } ], "description": "Anoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46700", "type": "HCPCS" } ], "description": "Repair of anal stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46705", "type": "HCPCS" } ], "description": "Repair of anal stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46706", "type": "HCPCS" } ], "description": "Repr of anal fistula w/glue", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46707", "type": "HCPCS" } ], "description": "Repair anorectal fist w/plug", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46710", "type": "HCPCS" } ], "description": "Repr per/vag pouch sngl proc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46712", "type": "HCPCS" } ], "description": "Repr per/vag pouch dbl proc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46715", "type": "HCPCS" } ], "description": "Rep perf anoper fistu", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46716", "type": "HCPCS" } ], "description": "Rep perf anoper/vestib fistu", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46730", "type": "HCPCS" } ], "description": "Construction of absent anus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46735", "type": "HCPCS" } ], "description": "Construction of absent anus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46740", "type": "HCPCS" } ], "description": "Construction of absent anus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46742", "type": "HCPCS" } ], "description": "Repair of imperforated anus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46744", "type": "HCPCS" } ], "description": "Repair of cloacal anomaly", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46746", "type": "HCPCS" } ], "description": "Repair of cloacal anomaly", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46748", "type": "HCPCS" } ], "description": "Repair of cloacal anomaly", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46750", "type": "HCPCS" } ], "description": "Repair of anal sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46751", "type": "HCPCS" } ], "description": "Repair of anal sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46753", "type": "HCPCS" } ], "description": "Reconstruction of anus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46754", "type": "HCPCS" } ], "description": "Removal of suture from anus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46760", "type": "HCPCS" } ], "description": "Repair of anal sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46761", "type": "HCPCS" } ], "description": "Repair of anal sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46900", "type": "HCPCS" } ], "description": "Destruction anal lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46910", "type": "HCPCS" } ], "description": "Destruction anal lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46916", "type": "HCPCS" } ], "description": "Cryosurgery anal lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46917", "type": "HCPCS" } ], "description": "Laser surgery anal lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46922", "type": "HCPCS" } ], "description": "Excision of anal lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46924", "type": "HCPCS" } ], "description": "Destruction anal lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46930", "type": "HCPCS" } ], "description": "Destroy internal hemorrhoids", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46940", "type": "HCPCS" } ], "description": "Treatment of anal fissure", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46942", "type": "HCPCS" } ], "description": "Treatment of anal fissure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46945", "type": "HCPCS" } ], "description": "Remove by ligat int hem grp", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46946", "type": "HCPCS" } ], "description": "Remove by ligat int hem grps", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46947", "type": "HCPCS" } ], "description": "Hemorrhoidopexy by stapling", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46948", "type": "HCPCS" } ], "description": "Int hrhc tranal dartlzj 2+", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2676.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2676.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "46999", "type": "HCPCS" } ], "description": "Anus surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47000", "type": "HCPCS" } ], "description": "Needle biopsy of liver", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47010", "type": "HCPCS" } ], "description": "Open drainage liver lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47015", "type": "HCPCS" } ], "description": "Inject/aspirate liver cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47100", "type": "HCPCS" } ], "description": "Wedge biopsy of liver", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47120", "type": "HCPCS" } ], "description": "Partial removal of liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47122", "type": "HCPCS" } ], "description": "Extensive removal of liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47125", "type": "HCPCS" } ], "description": "Partial removal of liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47130", "type": "HCPCS" } ], "description": "Partial removal of liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47133", "type": "HCPCS" } ], "description": "Removal of donor liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47135", "type": "HCPCS" } ], "description": "Transplantation of liver", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47140", "type": "HCPCS" } ], "description": "Partial removal donor liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47141", "type": "HCPCS" } ], "description": "Partial removal donor liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47142", "type": "HCPCS" } ], "description": "Partial removal donor liver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47143", "type": "HCPCS" } ], "description": "Prep donor liver whole", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47144", "type": "HCPCS" } ], "description": "Prep donor liver 3-segment", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47145", "type": "HCPCS" } ], "description": "Prep donor liver lobe split", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47146", "type": "HCPCS" } ], "description": "Prep donor liver/venous", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47147", "type": "HCPCS" } ], "description": "Prep donor liver/arterial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47300", "type": "HCPCS" } ], "description": "Surgery for liver lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47350", "type": "HCPCS" } ], "description": "Repair liver wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47360", "type": "HCPCS" } ], "description": "Repair liver wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47361", "type": "HCPCS" } ], "description": "Repair liver wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47362", "type": "HCPCS" } ], "description": "Repair liver wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47370", "type": "HCPCS" } ], "description": "Laparo ablate liver tumor rf", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47371", "type": "HCPCS" } ], "description": "Laparo ablate liver cryosurg", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47379", "type": "HCPCS" } ], "description": "Laparoscope procedure liver", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47380", "type": "HCPCS" } ], "description": "Open ablate liver tumor rf", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47381", "type": "HCPCS" } ], "description": "Open ablate liver tumor cryo", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47382", "type": "HCPCS" } ], "description": "Percut ablate liver rf", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47383", "type": "HCPCS" } ], "description": "Perq abltj lvr cryoablation", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47399", "type": "HCPCS" } ], "description": "Liver surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { 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schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47541", "type": "HCPCS" } ], "description": "Plmt access bil tree sm bwl", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47550", "type": "HCPCS" } ], "description": "Bile duct endoscopy add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", 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"plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47554", "type": "HCPCS" } ], "description": "Biliary endoscopy thru skin", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47555", "type": "HCPCS" } ], "description": "Biliary endoscopy thru skin", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, 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"HCPCS" } ], "description": "Laparoscopic cholecystectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47563", "type": "HCPCS" } ], "description": "Laparo cholecystectomy/graph", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47564", "type": "HCPCS" } ], "description": "Laparo cholecystectomy/explr", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47570", "type": "HCPCS" } ], "description": "Laparo cholecystoenterostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47579", "type": "HCPCS" } ], "description": "Laparoscope proc biliary", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47600", "type": "HCPCS" } ], "description": "Removal of gallbladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { 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{ "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47620", "type": "HCPCS" } ], "description": "Removal of gallbladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47700", "type": "HCPCS" } ], "description": "Exploration of bile ducts", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47701", "type": "HCPCS" } ], "description": "Bile duct revision", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47711", "type": "HCPCS" } ], "description": "Excision of bile duct tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47712", "type": "HCPCS" } ], "description": "Excision of bile duct tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47715", "type": "HCPCS" } ], "description": "Excision of bile duct cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47720", "type": "HCPCS" } ], "description": "Fuse gallbladder & bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47721", "type": "HCPCS" } ], "description": "Fuse upper gi structures", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47740", "type": "HCPCS" } ], "description": "Fuse gallbladder & bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47741", "type": "HCPCS" } ], "description": "Fuse gallbladder & bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47760", "type": "HCPCS" } ], "description": "Fuse bile ducts and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47765", "type": "HCPCS" } ], "description": "Fuse liver ducts & bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47780", "type": "HCPCS" } ], "description": "Fuse bile ducts and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47785", "type": "HCPCS" } ], "description": "Fuse bile ducts and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47800", "type": "HCPCS" } ], "description": "Reconstruction of bile ducts", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47801", "type": "HCPCS" } ], "description": "Placement bile duct support", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47802", "type": "HCPCS" } ], "description": "Fuse liver duct & intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47900", "type": "HCPCS" } ], "description": "Suture bile duct injury", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47999", "type": "HCPCS" } ], "description": "Bile tract surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48000", "type": "HCPCS" } ], "description": "Drainage of abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48001", "type": "HCPCS" } ], "description": "Placement of drain pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48020", "type": "HCPCS" } ], "description": "Removal of pancreatic stone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48100", "type": "HCPCS" } ], "description": "Biopsy of pancreas open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48102", "type": "HCPCS" } ], "description": "Needle biopsy pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48105", "type": "HCPCS" } ], "description": "Resect/Debride Pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48120", "type": "HCPCS" } ], "description": "Removal of pancreas lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48140", "type": "HCPCS" } ], "description": "Partial removal of pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48145", "type": "HCPCS" } ], "description": "Partial removal of pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48146", "type": "HCPCS" } ], "description": "Pancreatectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48148", "type": "HCPCS" } ], "description": "Removal of pancreatic duct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48150", "type": "HCPCS" } ], "description": "Partial removal of pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48152", "type": "HCPCS" } ], "description": "Pancreatectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48153", "type": "HCPCS" } ], "description": "Pancreatectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48154", "type": "HCPCS" } ], "description": "Pancreatectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48155", "type": "HCPCS" } ], "description": "Removal of pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48160", "type": "HCPCS" } ], "description": "Pancreas removal/transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48400", "type": "HCPCS" } ], "description": "Injection intraop add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48500", "type": "HCPCS" } ], "description": "Surgery of pancreatic cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48510", "type": "HCPCS" } ], "description": "Drain pancreatic pseudocyst", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48520", "type": "HCPCS" } ], "description": "Fuse pancreas cyst and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48540", "type": "HCPCS" } ], "description": "Fuse pancreas cyst and bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48545", "type": "HCPCS" } ], "description": "Pancreatorrhaphy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48547", "type": "HCPCS" } ], "description": "Duodenal exclusion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48548", "type": "HCPCS" } ], "description": "Fuse Pancreas and Bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48550", "type": "HCPCS" } ], "description": "Donor pancreatectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48551", "type": "HCPCS" } ], "description": "Prep donor pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48552", "type": "HCPCS" } ], "description": "Prep donor pancreas/venous", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48554", "type": "HCPCS" } ], "description": "Transpl allograft pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48556", "type": "HCPCS" } ], "description": "Removal allograft pancreas", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "48999", "type": "HCPCS" } ], "description": "Pancreas surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49000", "type": "HCPCS" } ], "description": "Exploration of abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49002", "type": "HCPCS" } ], "description": "Reopening of abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49010", "type": "HCPCS" } ], "description": "Exploration behind abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49013", "type": "HCPCS" } ], "description": "Prpertl pel pack hemrrg trma", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49014", "type": "HCPCS" } ], "description": "Reexploration pelvic wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49020", "type": "HCPCS" } ], "description": "Drainage abdom abscess open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49040", "type": "HCPCS" } ], "description": "Drain open abdom abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49060", "type": "HCPCS" } ], "description": "Drain open retroperi abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49062", "type": "HCPCS" } ], "description": "Drain to peritoneal cavity", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49082", "type": "HCPCS" } ], "description": "Abd paracentesis", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49083", "type": "HCPCS" } ], "description": "Abd paracentesis w/imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49084", "type": "HCPCS" } ], "description": "Peritoneal lavage", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49180", "type": "HCPCS" } ], "description": "Biopsy abdominal mass", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49185", "type": "HCPCS" } ], "description": "Sclerotx fluid collection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49203", "type": "HCPCS" } ], "description": "Exc abd tum 5 cm or less", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49204", "type": "HCPCS" } ], "description": "Exc abd tum over 5 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49205", "type": "HCPCS" } ], "description": "Exc abd tum over 10 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49215", "type": "HCPCS" } ], "description": "Excise sacral spine tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49250", "type": "HCPCS" } ], "description": "Excision of umbilicus", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49255", "type": "HCPCS" } ], "description": "Removal of omentum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49320", "type": "HCPCS" } ], "description": "Diag laparo separate proc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49321", "type": "HCPCS" } ], "description": "Laparoscopy biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49322", "type": "HCPCS" } ], "description": "Laparoscopy aspiration", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49323", "type": "HCPCS" } ], "description": "Laparo drain lymphocele", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49324", "type": "HCPCS" } ], "description": "Lap insert tunnel ip cath", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49325", "type": "HCPCS" } ], "description": "Lap Revision Perm IP Cath", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49329", "type": "HCPCS" } ], "description": "Laparo proc abdm/per/oment", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49402", "type": "HCPCS" } ], "description": "Remove foreign body adbomen", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49405", "type": "HCPCS" } ], "description": "Image cath fluid colxn visc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49406", "type": "HCPCS" } ], "description": "Image cath fluid peri/retro", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49407", "type": "HCPCS" } ], "description": "Image cath fluid trns/vgnl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49411", "type": "HCPCS" } ], "description": "Ins mark abd/pel for rt perq", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1334.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1334.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49412", "type": "HCPCS" } ], "description": "Ins device for rt guide open", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49418", "type": "HCPCS" } ], "description": "Insert tun ip cath perc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49419", "type": "HCPCS" } ], "description": "Insert tun ip cath w/port", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49421", "type": "HCPCS" } ], "description": "Ins tun ip cath for dial opn", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49422", "type": "HCPCS" } ], "description": "Remove tunneled ip cath", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49423", "type": "HCPCS" } ], "description": "Exchange drainage catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49425", "type": "HCPCS" } ], "description": "Insert abdomen-venous drain", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49426", "type": "HCPCS" } ], "description": "Revise abdomen-venous shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49428", "type": "HCPCS" } ], "description": "Ligation of shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49429", "type": "HCPCS" } ], "description": "Removal of shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49436", "type": "HCPCS" } ], "description": "Embedded IP Cath Exit-Site", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49440", "type": "HCPCS" } ], "description": "Place gastrostomy tube perc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49441", "type": "HCPCS" } ], "description": "Place duod/jej tube perc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49442", "type": "HCPCS" } ], "description": "Place cecostomy tube perc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49446", "type": "HCPCS" } ], "description": "Change g-tube to g-j perc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1850.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49450", "type": "HCPCS" } ], "description": "Replace g/c tube perc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49451", "type": "HCPCS" } ], "description": "Replace duod/jej tube perc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49452", "type": "HCPCS" } ], "description": "Replace g-j tube perc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49460", "type": "HCPCS" } ], "description": "Fix g/colon tube w/device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49465", "type": "HCPCS" } ], "description": "Fluoro exam of g/colon tube", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49491", "type": "HCPCS" } ], "description": "Rpr hern preemie reduc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49492", "type": "HCPCS" } ], "description": "Rpr ing hern premie blocked", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49495", "type": "HCPCS" } ], "description": "Rpr ing hernia baby reduc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49496", "type": "HCPCS" } ], "description": "Rpr ing hernia baby blocked", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49500", "type": "HCPCS" } ], "description": "Rpr ing hernia init reduce", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49501", "type": "HCPCS" } ], "description": "Rpr ing hernia init blocked", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49505", "type": "HCPCS" } ], "description": "Prp i/hern init reduc >5 yr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49507", "type": "HCPCS" } ], "description": "Prp i/hern init block >5 yr", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49520", "type": "HCPCS" } ], "description": "Rerepair ing hernia reduce", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49521", "type": "HCPCS" } ], "description": "Rerepair ing hernia blocked", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49525", "type": "HCPCS" } ], "description": "Repair ing hernia sliding", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49540", "type": "HCPCS" } ], "description": "Repair lumbar hernia", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49550", "type": "HCPCS" } ], "description": "Rpr rem hernia init reduce", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49553", "type": "HCPCS" } ], "description": "Rpr fem hernia init blocked", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49555", "type": "HCPCS" } ], "description": "Rerepair fem hernia reduce", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49557", "type": "HCPCS" } ], "description": "Rerepair fem hernia blocked", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49591", "type": "HCPCS" } ], "description": "Rpr aa hrn 1st < 3 cm rdc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49592", "type": "HCPCS" } ], "description": "Rpr aa hrn 1st < 3 ncr/strn", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49593", "type": "HCPCS" } ], "description": "Rpr aa hrn 1st 3-10 rdc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49594", "type": "HCPCS" } ], "description": "Rpr aa hrn 1st 3-10 ncr/strn", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49595", "type": "HCPCS" } ], "description": "Rpr aa hrn 1st > 10 rdc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49596", "type": "HCPCS" } ], "description": "Rpr aa hrn 1st > 10 ncr/strn", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49600", "type": "HCPCS" } ], "description": "Repair umbilical lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49605", "type": "HCPCS" } ], "description": "Repair umbilical lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49606", "type": "HCPCS" } ], "description": "Repair umbilical lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49610", "type": "HCPCS" } ], "description": "Repair umbilical lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49611", "type": "HCPCS" } ], "description": "Repair umbilical lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49613", "type": "HCPCS" } ], "description": "Rpr aa hrn rcr < 3 rdc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49614", "type": "HCPCS" } ], "description": "Rpr aa hrn rcr < 3 ncr/strn", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49615", "type": "HCPCS" } ], "description": "Rpr aa hrn rcr 3-10 rdc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49616", "type": "HCPCS" } ], "description": "Rpr aa hrn rcr 3-10 ncr/strn", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49617", "type": "HCPCS" } ], "description": "Rpr aa hrn rcr > 10 rdc", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49618", "type": "HCPCS" } ], "description": "Rpr aa hrn rcr > 10 ncr/strn", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49621", "type": "HCPCS" } ], "description": "Rpr parastomal hernia rdc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49622", "type": "HCPCS" } ], "description": "Rpr parastomal hrna ncr/strn", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49650", "type": "HCPCS" } ], "description": "Lap ing hernia repair init", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49651", "type": "HCPCS" } ], "description": "Lap ing hernia repair recur", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49659", "type": "HCPCS" } ], "description": "Laparo proc hernia repair", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49900", "type": "HCPCS" } ], "description": "Repair of abdominal wall", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49904", "type": "HCPCS" } ], "description": "Omental flap extra-abdom", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49905", "type": "HCPCS" } ], "description": "Omental flap intra-abdom", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49906", "type": "HCPCS" } ], "description": "Free omental flap microvasc", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "49999", "type": "HCPCS" } ], "description": "Abdomen surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50010", "type": "HCPCS" } ], "description": "Exploration of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50020", "type": "HCPCS" } ], "description": "Renal abscess open drain", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50040", "type": "HCPCS" } ], "description": "Drainage of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50045", "type": "HCPCS" } ], "description": "Exploration of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50060", "type": "HCPCS" } ], "description": "Removal of kidney stone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50065", "type": "HCPCS" } ], "description": "Incision of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50070", "type": "HCPCS" } ], "description": "Incision of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50075", "type": "HCPCS" } ], "description": "Removal of kidney stone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50080", "type": "HCPCS" } ], "description": "Removal of kidney stone", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50081", "type": "HCPCS" } ], "description": "Removal of kidney stone", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50100", "type": "HCPCS" } ], "description": "Revise kidney blood vessels", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50120", "type": "HCPCS" } ], "description": "Exploration of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50125", "type": "HCPCS" } ], "description": "Explore and drain kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50130", "type": "HCPCS" } ], "description": "Removal of kidney stone", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50135", "type": "HCPCS" } ], "description": "Exploration of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50200", "type": "HCPCS" } ], "description": "Renal biopsy perq", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50205", "type": "HCPCS" } ], "description": "Renal biopsy open", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50220", "type": "HCPCS" } ], "description": "Remove kidney open", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50225", "type": "HCPCS" } ], "description": "Removal kidney open complex", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50230", "type": "HCPCS" } ], "description": "Removal kidney open radical", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50234", "type": "HCPCS" } ], "description": "Removal of kidney & ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50236", "type": "HCPCS" } ], "description": "Removal of kidney & ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50240", "type": "HCPCS" } ], "description": "Partial removal of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50250", "type": "HCPCS" } ], "description": "Cryoablate renal mass open", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50280", "type": "HCPCS" } ], "description": "Removal of kidney lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50290", "type": "HCPCS" } ], "description": "Removal of kidney lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50300", "type": "HCPCS" } ], "description": "Remove cadaver donor kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50320", "type": "HCPCS" } ], "description": "Remove kidney living donor", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50323", "type": "HCPCS" } ], "description": "Prep cadaver renal allograft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50325", "type": "HCPCS" } ], "description": "Prep donor renal graft", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50327", "type": "HCPCS" } ], "description": "Prep renal graft/venous", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50328", "type": "HCPCS" } ], "description": "Prep renal graft/arterial", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50329", "type": "HCPCS" } ], "description": "Prep renal graft/ureteral", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50340", "type": "HCPCS" } ], "description": "Removal of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50360", "type": "HCPCS" } ], "description": "Transplantation of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50365", "type": "HCPCS" } ], "description": "Transplantation of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50370", "type": "HCPCS" } ], "description": "Remove transplanted kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50380", "type": "HCPCS" } ], "description": "Reimplantation of kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50382", "type": "HCPCS" } ], "description": "Change ureter stent percut", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50384", "type": "HCPCS" } ], "description": "Remove ureter stent percut", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50385", "type": "HCPCS" } ], "description": "Change stent via transureth", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50386", "type": "HCPCS" } ], "description": "Remove stent via transureth", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50387", "type": "HCPCS" } ], "description": "Change nephroureteral cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50389", "type": "HCPCS" } ], "description": "Remove renal tube w/fluoro", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50390", "type": "HCPCS" } ], "description": "Drainage of kidney lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50391", "type": "HCPCS" } ], "description": "Instll rx agnt into rnal tub", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50396", "type": "HCPCS" } ], "description": "Measure kidney pressure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50400", "type": "HCPCS" } ], "description": "Revision of kidney/ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50405", "type": "HCPCS" } ], "description": "Revision of kidney/ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50430", "type": "HCPCS" } ], "description": "Njx px nfrosgrm &/urtrgrm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50431", "type": "HCPCS" } ], "description": "Njx px nfrosgrm &/urtrgrm", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50432", "type": "HCPCS" } ], "description": "Plmt nephrostomy catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50433", "type": "HCPCS" } ], "description": "Plmt nephroureteral catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50434", "type": "HCPCS" } ], "description": "Convert nephrostomy catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50435", "type": "HCPCS" } ], "description": "Exchange nephrostomy cath", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50436", "type": "HCPCS" } ], "description": "Dilat xst trc ndurlgc px", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50437", "type": "HCPCS" } ], "description": "Dilat xst trc new access rcs", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50500", "type": "HCPCS" } ], "description": "Repair of kidney wound", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50520", "type": "HCPCS" } ], "description": "Close kidney-skin fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50525", "type": "HCPCS" } ], "description": "Close nephrovisceral fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50526", "type": "HCPCS" } ], "description": "Close nephrovisceral fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50540", "type": "HCPCS" } ], "description": "Revision of horseshoe kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50541", "type": "HCPCS" } ], "description": "Laparo ablate renal cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50542", "type": "HCPCS" } ], "description": "Laparo ablate renal mass", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50543", "type": "HCPCS" } ], "description": "Laparo partial nephrectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50544", "type": "HCPCS" } ], "description": "Laparoscopy pyeloplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50545", "type": "HCPCS" } ], "description": "Laparo Radical Nephrectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50546", "type": "HCPCS" } ], "description": "Laparoscopic nephrectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50547", "type": "HCPCS" } ], "description": "Laparo removal donor kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50548", "type": "HCPCS" } ], "description": "Laparo remove w/ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50549", "type": "HCPCS" } ], "description": "Laparoscope proc renal", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50551", "type": "HCPCS" } ], "description": "Kidney endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50553", "type": "HCPCS" } ], "description": "Kidney endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50555", "type": "HCPCS" } ], "description": "Kidney endoscopy & biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50557", "type": "HCPCS" } ], "description": "Kidney endoscopy & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50561", "type": "HCPCS" } ], "description": "Kidney endoscopy & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50562", "type": "HCPCS" } ], "description": "Renal scope w/tumor resect", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50570", "type": "HCPCS" } ], "description": "Kidney endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50572", "type": "HCPCS" } ], "description": "Kidney endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50574", "type": "HCPCS" } ], "description": "Kidney endoscopy & biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50575", "type": "HCPCS" } ], "description": "Kidney endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50576", "type": "HCPCS" } ], "description": "Kidney endoscopy & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50580", "type": "HCPCS" } ], "description": "Kidney endoscopy & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50590", "type": "HCPCS" } ], "description": "Fragmenting of kidney stone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50592", "type": "HCPCS" } ], "description": "Perc rf ablate renal tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50593", "type": "HCPCS" } ], "description": "Perc cryo ablate renal tum", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50600", "type": "HCPCS" } ], "description": "Exploration of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50605", "type": "HCPCS" } ], "description": "Insert ureteral support", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50610", "type": "HCPCS" } ], "description": "Removal of ureter stone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50620", "type": "HCPCS" } ], "description": "Removal of ureter stone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50630", "type": "HCPCS" } ], "description": "Removal of ureter stone", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50650", "type": "HCPCS" } ], "description": "Removal of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50660", "type": "HCPCS" } ], "description": "Removal of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50686", "type": "HCPCS" } ], "description": "Measure ureter pressure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50688", "type": "HCPCS" } ], "description": "Change of ureter tube/stent", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50693", "type": "HCPCS" } ], "description": "Plmt ureteral stent prq", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50694", "type": "HCPCS" } ], "description": "Plmt ureteral stent prq", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50695", "type": "HCPCS" } ], "description": "Plmt ureteral stent prq", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50700", "type": "HCPCS" } ], "description": "Revision of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50715", "type": "HCPCS" } ], "description": "Release of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50722", "type": "HCPCS" } ], "description": "Release of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50725", "type": "HCPCS" } ], "description": "Release/revise ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50727", "type": "HCPCS" } ], "description": "Revise ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50728", "type": "HCPCS" } ], "description": "Revise ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50740", "type": "HCPCS" } ], "description": "Fusion of ureter & kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50750", "type": "HCPCS" } ], "description": "Fusion of ureter & kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50760", "type": "HCPCS" } ], "description": "Fusion of ureters", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50770", "type": "HCPCS" } ], "description": "Splicing of ureters", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50780", "type": "HCPCS" } ], "description": "Reimplant ureter in bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50782", "type": "HCPCS" } ], "description": "Reimplant ureter in bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50783", "type": "HCPCS" } ], "description": "Reimplant ureter in bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50785", "type": "HCPCS" } ], "description": "Reimplant ureter in bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50800", "type": "HCPCS" } ], "description": "Implant ureter in bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50810", "type": "HCPCS" } ], "description": "Fusion of ureter & bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50815", "type": "HCPCS" } ], "description": "Urine shunt to intestine", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50820", "type": "HCPCS" } ], "description": "Construct bowel bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50825", "type": "HCPCS" } ], "description": "Construct bowel bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50830", "type": "HCPCS" } ], "description": "Revise urine flow", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50840", "type": "HCPCS" } ], "description": "Replace ureter by bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50845", "type": "HCPCS" } ], "description": "Appendico-vesicostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50860", "type": "HCPCS" } ], "description": "Transplant ureter to skin", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50900", "type": "HCPCS" } ], "description": "Repair of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50920", "type": "HCPCS" } ], "description": "Closure ureter/skin fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50930", "type": "HCPCS" } ], "description": "Closure ureter/bowel fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50940", "type": "HCPCS" } ], "description": "Release of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50945", "type": "HCPCS" } ], "description": "Laparoscopy ureterolithotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50947", "type": "HCPCS" } ], "description": "Laparo New Ureter/Bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50948", "type": "HCPCS" } ], "description": "Laparo New Ureter/Bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50949", "type": "HCPCS" } ], "description": "Laparoscope proc ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50951", "type": "HCPCS" } ], "description": "Endoscopy of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50953", "type": "HCPCS" } ], "description": "Endoscopy of ureter", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50955", "type": "HCPCS" } ], "description": "Ureter endoscopy & biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50957", "type": "HCPCS" } ], "description": "Ureter endoscopy & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "50961", "type": "HCPCS" } ], "description": "Ureter endoscopy & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", 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9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51500", "type": "HCPCS" } ], "description": "Removal of bladder cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51520", "type": "HCPCS" } ], "description": "Removal of bladder lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51525", "type": "HCPCS" } ], "description": "Removal of bladder lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51530", "type": "HCPCS" } ], "description": "Removal of bladder lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51535", "type": "HCPCS" } ], "description": "Repair of ureter lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51550", "type": "HCPCS" } ], "description": "Partial removal of bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51555", "type": "HCPCS" } ], "description": "Partial removal of bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51565", "type": "HCPCS" } ], "description": "Revise bladder & ureter(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51570", "type": "HCPCS" } ], "description": "Removal of bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51575", "type": "HCPCS" } ], "description": "Removal of bladder & nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51580", "type": "HCPCS" } ], "description": "Remove bladder/revise tract", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51585", "type": "HCPCS" } ], "description": "Removal of bladder & nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51590", "type": "HCPCS" } ], "description": "Remove bladder/revise tract", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51595", "type": "HCPCS" } ], "description": "Remove bladder/revise tract", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51596", "type": "HCPCS" } ], "description": "Remove bladder/create pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51597", "type": "HCPCS" } ], "description": "Removal of pelvic structures", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51700", "type": "HCPCS" } ], "description": "Irrigation of bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51701", "type": "HCPCS" } ], "description": "Insert bladder catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51702", "type": "HCPCS" } ], "description": "Insert temp bladder cath", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51703", "type": "HCPCS" } ], "description": "Insert bladder cath complex", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51705", "type": "HCPCS" } ], "description": "Change of bladder tube", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51710", "type": "HCPCS" } ], "description": "Change of bladder tube", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": 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Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52341", "type": "HCPCS" } ], "description": "Cysto W/Ureter Stricture Tx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52342", "type": "HCPCS" } ], "description": "Cysto W/Up Stricture Tx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care 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"setting": "outpatient" } ] }, { "code_information": [ { "code": "52352", "type": "HCPCS" } ], "description": "Cystouretero w/stone remove", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52353", "type": "HCPCS" } ], "description": "Cystouretero W/Lithotripsy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52354", "type": "HCPCS" } ], "description": "Cystouretero W/Biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52355", "type": "HCPCS" } ], "description": "Cystouretero W/Excise Tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52356", "type": "HCPCS" } ], "description": "Cysto/uretero w/lithotripsy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52400", "type": "HCPCS" } ], "description": "Cystouretero W/Congen Repr", "standard_charges": [ { "billing_class": 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{ "code": "52648", "type": "HCPCS" } ], "description": "Laser surgery of prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52649", "type": "HCPCS" } ], "description": "Prostate laser enucleation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": 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"additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53025", "type": "HCPCS" } ], "description": "Incision of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53040", "type": "HCPCS" } ], "description": "Drainage of urethra abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53060", "type": "HCPCS" } ], "description": "Drainage of urethra abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53080", "type": "HCPCS" } ], "description": "Drainage of urinary leakage", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53085", "type": "HCPCS" } ], "description": "Drainage of urinary leakage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53200", "type": "HCPCS" } ], "description": "Biopsy of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53210", "type": "HCPCS" } ], "description": "Removal of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53215", "type": "HCPCS" } ], "description": "Removal of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53220", "type": "HCPCS" } ], "description": "Treatment of urethra lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53230", "type": "HCPCS" } ], "description": "Removal of urethra lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53235", "type": "HCPCS" } ], "description": "Removal of urethra lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53240", "type": "HCPCS" } ], "description": "Surgery for urethra pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53250", "type": "HCPCS" } ], "description": "Removal of urethra gland", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53260", "type": "HCPCS" } ], "description": "Treatment of urethra lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53265", "type": "HCPCS" } ], "description": "Treatment of urethra lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53270", "type": "HCPCS" } ], "description": "Removal of urethra gland", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53275", "type": "HCPCS" } ], "description": "Repair of urethra defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53400", "type": "HCPCS" } ], "description": "Revise urethra stage 1", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53405", "type": "HCPCS" } ], "description": "Revise urethra stage 2", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53410", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53415", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53420", "type": "HCPCS" } ], "description": "Reconstruct urethra stage 1", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53425", "type": "HCPCS" } ], "description": "Reconstruct urethra stage 2", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53430", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53431", "type": "HCPCS" } ], "description": "Reconstruct urethra/bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53440", "type": "HCPCS" } ], "description": "Male sling procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12721.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12721.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53442", "type": "HCPCS" } ], "description": "Remove/revise male sling", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53444", "type": "HCPCS" } ], "description": "Insert tandem cuff", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53445", "type": "HCPCS" } ], "description": "Insert uro/ves nck sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53446", "type": "HCPCS" } ], "description": "Remove uro sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53447", "type": "HCPCS" } ], "description": "Remove/replace ur sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53448", "type": "HCPCS" } ], "description": "Remov/replc ur sphinctr comp", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53449", "type": "HCPCS" } ], "description": "Repair uro sphincter", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53450", "type": "HCPCS" } ], "description": "Revision of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53451", "type": "HCPCS" } ], "description": "Tprnl balo cntnc dev bi", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 12721.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12721.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53452", "type": "HCPCS" } ], "description": "Tprnl balo cntnc dev uni", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53453", "type": "HCPCS" } ], "description": "Tprnl balo cntnc dev rmvl ea", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53454", "type": "HCPCS" } ], "description": "Tprnl balo cntnc dev adjmt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53460", "type": "HCPCS" } ], "description": "Revision of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53500", "type": "HCPCS" } ], "description": "Urethrlys transvag w/ scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53502", "type": "HCPCS" } ], "description": "Repair of urethra injury", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53505", "type": "HCPCS" } ], "description": "Repair of urethra injury", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53510", "type": "HCPCS" } ], "description": "Repair of urethra injury", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53515", "type": "HCPCS" } ], "description": "Repair of urethra injury", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53520", "type": "HCPCS" } ], "description": "Repair of urethra defect", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53600", "type": "HCPCS" } ], "description": "Dilate urethra stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53601", "type": "HCPCS" } ], "description": "Dilate urethra stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53605", "type": "HCPCS" } ], "description": "Dilate urethra stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53620", "type": "HCPCS" } ], "description": "Dilate urethra stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53621", "type": "HCPCS" } ], "description": "Dilate urethra stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53660", "type": "HCPCS" } ], "description": "Dilation of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53661", "type": "HCPCS" } ], "description": "Dilation of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53665", "type": "HCPCS" } ], "description": "Dilation of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53850", "type": "HCPCS" } ], "description": "Prostatic microwave thermotx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53852", "type": "HCPCS" } ], "description": "Prostatic rf thermotx", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53854", "type": "HCPCS" } ], "description": "Trurl dstrj prst8 tiss rf wv", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53855", "type": "HCPCS" } ], "description": "Insert prost urethral stent", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53860", "type": "HCPCS" } ], "description": "Transurethral rf treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "53899", "type": "HCPCS" } ], "description": "Urology surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54000", "type": "HCPCS" } ], "description": "Slitting of prepuce", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54001", "type": "HCPCS" } ], "description": "Slitting of prepuce", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54015", "type": "HCPCS" } ], "description": "Drain penis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54050", "type": "HCPCS" } ], "description": "Destruction penis lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54055", "type": "HCPCS" } ], "description": "Destruction penis lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54056", "type": "HCPCS" } ], "description": "Cryosurgery penis lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54057", "type": "HCPCS" } ], "description": "Laser surg penis lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54060", "type": "HCPCS" } ], "description": "Excision of penis lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54065", "type": "HCPCS" } ], "description": "Destruction penis lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54100", "type": "HCPCS" } ], "description": "Biopsy of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54105", "type": "HCPCS" } ], "description": "Biopsy of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54110", "type": "HCPCS" } ], "description": "Treatment of penis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54111", "type": "HCPCS" } ], "description": "Treat penis lesion graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54112", "type": "HCPCS" } ], "description": "Treat penis lesion graft", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54115", "type": "HCPCS" } ], "description": "Treatment of penis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54120", "type": "HCPCS" } ], "description": "Partial removal of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54125", "type": "HCPCS" } ], "description": "Removal of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54130", "type": "HCPCS" } ], "description": "Remove penis & nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54135", "type": "HCPCS" } ], "description": "Remove penis & nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54150", "type": "HCPCS" } ], "description": "Circumcision w/regionl block", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54160", "type": "HCPCS" } ], "description": "Circumcision neonate", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54161", "type": "HCPCS" } ], "description": "Circum 28 days or older", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54162", "type": "HCPCS" } ], "description": "Lysis penil circumic lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54163", "type": "HCPCS" } ], "description": "Repair of circumcision", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54164", "type": "HCPCS" } ], "description": "Frenulotomy of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54200", "type": "HCPCS" } ], "description": "Treatment of penis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54205", "type": "HCPCS" } ], "description": "Treatment of penis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54220", "type": "HCPCS" } ], "description": "Treatment of penis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54231", "type": "HCPCS" } ], "description": "Dynamic cavernosometry", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54235", "type": "HCPCS" } ], "description": "Penile injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54240", "type": "HCPCS" } ], "description": "Penis study", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54250", "type": "HCPCS" } ], "description": "Penis study", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54300", "type": "HCPCS" } ], "description": "Revision of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54304", "type": "HCPCS" } ], "description": "Revision of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54308", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54312", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54316", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54318", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54322", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54324", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54326", "type": "HCPCS" } ], "description": "Reconstruction of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54328", "type": "HCPCS" } ], "description": "Revise penis/urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54332", "type": "HCPCS" } ], "description": "Revise penis/urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54336", "type": "HCPCS" } ], "description": "Revise penis/urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54340", "type": "HCPCS" } ], "description": "Secondary urethral surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54344", "type": "HCPCS" } ], "description": "Secondary urethral surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54348", "type": "HCPCS" } ], "description": "Secondary urethral surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54352", "type": "HCPCS" } ], "description": "Reconstruct urethra/penis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54360", "type": "HCPCS" } ], "description": "Penis plastic surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54380", "type": "HCPCS" } ], "description": "Repair penis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54385", "type": "HCPCS" } ], "description": "Repair penis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54390", "type": "HCPCS" } ], "description": "Repair penis and bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54400", "type": "HCPCS" } ], "description": "Insert semi-rigid prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 12721.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12721.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54401", "type": "HCPCS" } ], "description": "Insert self-contd prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54405", "type": "HCPCS" } ], "description": "Insert multi-comp penis pros", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54406", "type": "HCPCS" } ], "description": "Remove muti-comp penis pros", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54408", "type": "HCPCS" } ], "description": "Repair multi-comp penis pros", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54410", "type": "HCPCS" } ], "description": "Remove/replace penis prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54411", "type": "HCPCS" } ], "description": "Remov/replc penis pros comp", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54415", "type": "HCPCS" } ], "description": "Remove self-contd penis pros", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54416", "type": "HCPCS" } ], "description": "Remv/repl penis contain pros", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54417", "type": "HCPCS" } ], "description": "Remv/replc penis pros compl", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 19984.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19984.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54420", "type": "HCPCS" } ], "description": "Revision of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54430", "type": "HCPCS" } ], "description": "Revision of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54435", "type": "HCPCS" } ], "description": "Revision of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54437", "type": "HCPCS" } ], "description": "Repair corporeal tear", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54438", "type": "HCPCS" } ], "description": "Replantation of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 63079.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54440", "type": "HCPCS" } ], "description": "Repair of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54450", "type": "HCPCS" } ], "description": "Preputial stretching", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54500", "type": "HCPCS" } ], "description": "Biopsy of testis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54505", "type": "HCPCS" } ], "description": "Biopsy of testis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54512", "type": "HCPCS" } ], "description": "Excise Lesion Testis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54520", "type": "HCPCS" } ], "description": "Removal of testis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54522", "type": "HCPCS" } ], "description": "Orchiectomy partial", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54530", "type": "HCPCS" } ], "description": "Removal of testis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54535", "type": "HCPCS" } ], "description": "Extensive testis surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54550", "type": "HCPCS" } ], "description": "Exploration for testis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54560", "type": "HCPCS" } ], "description": "Exploration for testis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54600", "type": "HCPCS" } ], "description": "Reduce testis torsion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54620", "type": "HCPCS" } ], "description": "Suspension of testis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54640", "type": "HCPCS" } ], "description": "Suspension of testis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54650", "type": "HCPCS" } ], "description": "Orchiopexy (Fowler-Stephens)", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54660", "type": "HCPCS" } ], "description": "Revision of testis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54670", "type": "HCPCS" } ], "description": "Repair testis injury", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54680", "type": "HCPCS" } ], "description": "Relocation of testis(es)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54690", "type": "HCPCS" } ], "description": "Laparoscopy orchiectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54692", "type": "HCPCS" } ], "description": "Laparoscopy orchiopexy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54699", "type": "HCPCS" } ], "description": "Laparoscope proc testis", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54700", "type": "HCPCS" } ], "description": "Drainage of scrotum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54800", "type": "HCPCS" } ], "description": "Biopsy of epididymis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54830", "type": "HCPCS" } ], "description": "Remove epididymis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54840", "type": "HCPCS" } ], "description": "Remove epididymis lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54860", "type": "HCPCS" } ], "description": "Removal of epididymis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54861", "type": "HCPCS" } ], "description": "Removal of epididymis", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54865", "type": "HCPCS" } ], "description": "Explore Epididymis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54900", "type": "HCPCS" } ], "description": "Fusion of spermatic ducts", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "54901", "type": "HCPCS" } ], "description": "Fusion of spermatic ducts", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55000", "type": "HCPCS" } ], "description": "Drainage of hydrocele", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55040", "type": "HCPCS" } ], "description": "Removal of hydrocele", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55041", "type": "HCPCS" } ], "description": "Removal of hydroceles", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55060", "type": "HCPCS" } ], "description": "Repair of hydrocele", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55100", "type": "HCPCS" } ], "description": "Drainage of scrotum abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55110", "type": "HCPCS" } ], "description": "Explore scrotum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55120", "type": "HCPCS" } ], "description": "Removal of scrotum lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55150", "type": "HCPCS" } ], "description": "Removal of scrotum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55175", "type": "HCPCS" } ], "description": "Revision of scrotum", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55180", "type": "HCPCS" } ], "description": "Revision of scrotum", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55200", "type": "HCPCS" } ], "description": "Incision of sperm duct", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55250", "type": "HCPCS" } ], "description": "Removal of sperm duct(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55400", "type": "HCPCS" } ], "description": "Repair of sperm duct", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55500", "type": "HCPCS" } ], "description": "Removal of hydrocele", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55520", "type": "HCPCS" } ], "description": "Removal of sperm cord lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55530", "type": "HCPCS" } ], "description": "Revise spermatic cord veins", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55535", "type": "HCPCS" } ], "description": "Revise spermatic cord veins", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55540", "type": "HCPCS" } ], "description": "Revise hernia & sperm veins", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3452.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3452.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55550", "type": "HCPCS" } ], "description": "Laparo ligate spermatic vein", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55559", "type": "HCPCS" } ], "description": "Laparo proc spermatic cord", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55600", "type": "HCPCS" } ], "description": "Incise sperm duct pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55605", "type": "HCPCS" } ], "description": "Incise sperm duct pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55650", "type": "HCPCS" } ], "description": "Remove sperm duct pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55680", "type": "HCPCS" } ], "description": "Remove sperm pouch lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55700", "type": "HCPCS" } ], "description": "Biopsy of prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55705", "type": "HCPCS" } ], "description": "Biopsy of prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55706", "type": "HCPCS" } ], "description": "Prostate saturation sampling", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55720", "type": "HCPCS" } ], "description": "Drainage of prostate abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55725", "type": "HCPCS" } ], "description": "Drainage of prostate abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55801", "type": "HCPCS" } ], "description": "Removal of prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55810", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55812", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55815", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55821", "type": "HCPCS" } ], "description": "Removal of prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55831", "type": "HCPCS" } ], "description": "Removal of prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55840", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55842", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55845", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55860", "type": "HCPCS" } ], "description": "Surgical exposure prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55862", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55865", "type": "HCPCS" } ], "description": "Extensive prostate surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55866", "type": "HCPCS" } ], "description": "Laparo radical prostatectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55867", "type": "HCPCS" } ], "description": "Laps surg prst8ect smpl stot", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55870", "type": "HCPCS" } ], "description": "Electroejaculation", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55873", "type": "HCPCS" } ], "description": "Cryoablate Prostate", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55874", "type": "HCPCS" } ], "description": "Tprnl plmt biodegrdabl matrl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55875", "type": "HCPCS" } ], "description": "Transperi needle place pros", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55876", "type": "HCPCS" } ], "description": "Place rt device/marker pros", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1334.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1334.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55880", "type": "HCPCS" } ], "description": "Abltj mal prst8 tiss hifu", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55899", "type": "HCPCS" } ], "description": "Genital surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55920", "type": "HCPCS" } ], "description": "Place needles pelvic for rt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55970", "type": "HCPCS" } ], "description": "Sex transformation m to f", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55980", "type": "HCPCS" } ], "description": "Sex transformation f to m", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56405", "type": "HCPCS" } ], "description": "I & D of vulva/perineum", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56420", "type": "HCPCS" } ], "description": "Drainage of gland abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56440", "type": "HCPCS" } ], "description": "Surgery for vulva lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56441", "type": "HCPCS" } ], "description": "Lysis of labial lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56442", "type": "HCPCS" } ], "description": "Hymenotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56501", "type": "HCPCS" } ], "description": "Destroy vulva lesions sim", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56515", "type": "HCPCS" } ], "description": "Destroy vulva lesion/s compl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56605", "type": "HCPCS" } ], "description": "Biopsy of vulva/perineum", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56620", "type": "HCPCS" } ], "description": "Partial removal of vulva", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56625", "type": "HCPCS" } ], "description": "Complete removal of vulva", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56630", "type": "HCPCS" } ], "description": "Extensive vulva surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56631", "type": "HCPCS" } ], "description": "Extensive vulva surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56632", "type": "HCPCS" } ], "description": "Extensive vulva surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56633", "type": "HCPCS" } ], "description": "Extensive vulva surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56634", "type": "HCPCS" } ], "description": "Extensive vulva surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56637", "type": "HCPCS" } ], "description": "Extensive vulva surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56640", "type": "HCPCS" } ], "description": "Extensive vulva surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56700", "type": "HCPCS" } ], "description": "Partial removal of hymen", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56740", "type": "HCPCS" } ], "description": "Remove vagina gland lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56800", "type": "HCPCS" } ], "description": "Repair of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56805", "type": "HCPCS" } ], "description": "Repair clitoris", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56810", "type": "HCPCS" } ], "description": "Repair of perineum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56820", "type": "HCPCS" } ], "description": "Exam of vulva w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "56821", "type": "HCPCS" } ], "description": "Exam/biopsy of vulva w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57000", "type": "HCPCS" } ], "description": "Exploration of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57010", "type": "HCPCS" } ], "description": "Drainage of pelvic abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57020", "type": "HCPCS" } ], "description": "Drainage of pelvic fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57022", "type": "HCPCS" } ], "description": "I & d vaginal hematoma pp", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57023", "type": "HCPCS" } ], "description": "I & d vag hematoma non-ob", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 2800.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2800.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57061", "type": "HCPCS" } ], "description": "Destroy vag lesions simple", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57065", "type": "HCPCS" } ], "description": "Destroy vag lesions complex", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57100", "type": "HCPCS" } ], "description": "Biopsy of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57105", "type": "HCPCS" } ], "description": "Biopsy of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57106", "type": "HCPCS" } ], "description": "Remove vagina wall partial", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57107", "type": "HCPCS" } ], "description": "Remove vagina tissue part", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57109", "type": "HCPCS" } ], "description": "Vaginectomy partial w/nodes", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57110", "type": "HCPCS" } ], "description": "Remove vagina wall complete", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57111", "type": "HCPCS" } ], "description": "Remove vagina tissue compl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57120", "type": "HCPCS" } ], "description": "Closure of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57130", "type": "HCPCS" } ], "description": "Remove vagina lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57135", "type": "HCPCS" } ], "description": "Remove vagina lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57150", "type": "HCPCS" } ], "description": "Treat vagina infection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57155", "type": "HCPCS" } ], "description": "Insert uteri tandem/ovoids", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57156", "type": "HCPCS" } ], "description": "Ins vag brachytx device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57160", "type": "HCPCS" } ], "description": "Insert pessary/other device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57170", "type": "HCPCS" } ], "description": "Fitting of diaphragm/cap", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57180", "type": "HCPCS" } ], "description": "Treat vaginal bleeding", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57200", "type": "HCPCS" } ], "description": "Repair of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57210", "type": "HCPCS" } ], "description": "Repair vagina/perineum", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57220", "type": "HCPCS" } ], "description": "Revision of urethra", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57230", "type": "HCPCS" } ], "description": "Repair of urethral lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57240", "type": "HCPCS" } ], "description": "Repair bladder & vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57250", "type": "HCPCS" } ], "description": "Repair rectum & vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57260", "type": "HCPCS" } ], "description": "Repair of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57265", "type": "HCPCS" } ], "description": "Extensive repair of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57268", "type": "HCPCS" } ], "description": "Repair of bowel bulge", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57270", "type": "HCPCS" } ], "description": "Repair of bowel pouch", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57280", "type": "HCPCS" } ], "description": "Suspension of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57282", "type": "HCPCS" } ], "description": "Colpopexy extraperitoneal", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57283", "type": "HCPCS" } ], "description": "Colpopexy intraperitoneal", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57284", "type": "HCPCS" } ], "description": "Repair paravag defect open", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57285", "type": "HCPCS" } ], "description": "Repair paravag defect vag", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57287", "type": "HCPCS" } ], "description": "Revise/Remove Sling Repair", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57288", "type": "HCPCS" } ], "description": "Repair bladder defect", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57289", "type": "HCPCS" } ], "description": "Repair bladder & vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57291", "type": "HCPCS" } ], "description": "Construction of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57292", "type": "HCPCS" } ], "description": "Construct vagina with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57295", "type": "HCPCS" } ], "description": "Revise vag graft via vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57296", "type": "HCPCS" } ], "description": "Revise vag graft open abd", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57300", "type": "HCPCS" } ], "description": "Repair rectum-vagina fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57305", "type": "HCPCS" } ], "description": "Repair rectum-vagina fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57307", "type": "HCPCS" } ], "description": "Fistula repair & colostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57308", "type": "HCPCS" } ], "description": "Fistula repair transperine", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57310", "type": "HCPCS" } ], "description": "Repair urethrovaginal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57311", "type": "HCPCS" } ], "description": "Repair urethrovaginal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57320", "type": "HCPCS" } ], "description": "Repair bladder-vagina lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57330", "type": "HCPCS" } ], "description": "Repair bladder-vagina lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57335", "type": "HCPCS" } ], "description": "Repair vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57400", "type": "HCPCS" } ], "description": "Dilation of vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57410", "type": "HCPCS" } ], "description": "Pelvic examination", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57415", "type": "HCPCS" } ], "description": "Remove vaginal foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57420", "type": "HCPCS" } ], "description": "Exam of vagina w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57421", "type": "HCPCS" } ], "description": "Exam/biopsy of vag w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57423", "type": "HCPCS" } ], "description": "Repair paravag defect lap", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57425", "type": "HCPCS" } ], "description": "Laparoscopy surg colpopexy", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57426", "type": "HCPCS" } ], "description": "Revise prosth vag graft lap", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57452", "type": "HCPCS" } ], "description": "Exam of cervix w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57454", "type": "HCPCS" } ], "description": "Bx/curett of cervix w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57455", "type": "HCPCS" } ], "description": "Biopsy of cervix w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57456", "type": "HCPCS" } ], "description": "Endocerv curettage w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57460", "type": "HCPCS" } ], "description": "Bx of cervix w/scope leep", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57461", "type": "HCPCS" } ], "description": "Conz of cervix w/scope leep", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57500", "type": "HCPCS" } ], "description": "Biopsy of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57505", "type": "HCPCS" } ], "description": "Endocervical curettage", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57510", "type": "HCPCS" } ], "description": "Cauterization of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57511", "type": "HCPCS" } ], "description": "Cryocautery of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57513", "type": "HCPCS" } ], "description": "Laser surgery of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57520", "type": "HCPCS" } ], "description": "Conization of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57522", "type": "HCPCS" } ], "description": "Conization of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57530", "type": "HCPCS" } ], "description": "Removal of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57531", "type": "HCPCS" } ], "description": "Removal of cervix radical", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57540", "type": "HCPCS" } ], "description": "Removal of residual cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57545", "type": "HCPCS" } ], "description": "Remove cervix/repair pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57550", "type": "HCPCS" } ], "description": "Removal of residual cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57555", "type": "HCPCS" } ], "description": "Remove cervix/repair vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57556", "type": "HCPCS" } ], "description": "Remove cervix repair bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57558", "type": "HCPCS" } ], "description": "D&C oF Cervical Stump", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57700", "type": "HCPCS" } ], "description": "Revision of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57720", "type": "HCPCS" } ], "description": "Revision of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "57800", "type": "HCPCS" } ], "description": "Dilation of cervical canal", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58100", "type": "HCPCS" } ], "description": "Biopsy of uterus lining", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58120", "type": "HCPCS" } ], "description": "Dilation and curettage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58140", "type": "HCPCS" } ], "description": "Myomectomy abdom method", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58145", "type": "HCPCS" } ], "description": "Myomectomy vag method", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58146", "type": "HCPCS" } ], "description": "Myomectomy abdom complex", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58150", "type": "HCPCS" } ], "description": "Total hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58152", "type": "HCPCS" } ], "description": "Total hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58180", "type": "HCPCS" } ], "description": "Partial hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58200", "type": "HCPCS" } ], "description": "Extensive hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58210", "type": "HCPCS" } ], "description": "Extensive hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58240", "type": "HCPCS" } ], "description": "Removal of pelvis contents", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58260", "type": "HCPCS" } ], "description": "Vaginal hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58262", "type": "HCPCS" } ], "description": "Vag hyst including t/o", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58263", "type": "HCPCS" } ], "description": "Vag hyst w/t/o & vag repair", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58267", "type": "HCPCS" } ], "description": "Vag hyst w/urinary repair", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58270", "type": "HCPCS" } ], "description": "Vag hyst w/enterocele repair", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58275", "type": "HCPCS" } ], "description": "Hysterectomy/revise vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58280", "type": "HCPCS" } ], "description": "Hysterectomy/revise vagina", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58285", "type": "HCPCS" } ], "description": "Extensive hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58290", "type": "HCPCS" } ], "description": "Vag hyst complex", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58291", "type": "HCPCS" } ], "description": "Vag hyst incl t/o complex", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58292", "type": "HCPCS" } ], "description": "Vag hyst t/o & repair compl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58294", "type": "HCPCS" } ], "description": "Vag hyst w/enterocele compl", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58300", "type": "HCPCS" } ], "description": "Insert intrauterine device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58301", "type": "HCPCS" } ], "description": "Remove intrauterine device", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58321", "type": "HCPCS" } ], "description": "Artificial insemination", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58322", "type": "HCPCS" } ], "description": "Artificial insemination", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58323", "type": "HCPCS" } ], "description": "Sperm washing", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58345", "type": "HCPCS" } ], "description": "Reopen fallopian tube", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58346", "type": "HCPCS" } ], "description": "Insert heyman uteri capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58350", "type": "HCPCS" } ], "description": "Reopen fallopian tube", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58353", "type": "HCPCS" } ], "description": "Endometr ablate thermal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58356", "type": "HCPCS" } ], "description": "Endometrial cryoablation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58400", "type": "HCPCS" } ], "description": "Suspension of uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58410", "type": "HCPCS" } ], "description": "Suspension of uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58520", "type": "HCPCS" } ], "description": "Repair of ruptured uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58540", "type": "HCPCS" } ], "description": "Revision of uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58541", "type": "HCPCS" } ], "description": "Lsh uterus 250 g or less", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58542", "type": "HCPCS" } ], "description": "Lsh w/t/o ut 250 g or less", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58543", "type": "HCPCS" } ], "description": "LSH Uterus Above 250 g", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58544", "type": "HCPCS" } ], "description": "LSH w/t/o Uterus Above 250 g", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58545", "type": "HCPCS" } ], "description": "Laparoscopic myomectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58546", "type": "HCPCS" } ], "description": "Laparo-myomectomy complex", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58548", "type": "HCPCS" } ], "description": "Lap Radical Hyst", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58550", "type": "HCPCS" } ], "description": "Laparo-asst vag hysterectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58552", "type": "HCPCS" } ], "description": "Laparo-vag hyst incl t/o", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58553", "type": "HCPCS" } ], "description": "Laparo-vag hyst complex", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58554", "type": "HCPCS" } ], "description": "Laparo-vag hyst w/t/o compl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58555", "type": "HCPCS" } ], "description": "Hysteroscopy dx sep proc", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58558", "type": "HCPCS" } ], "description": "Hysteroscopy biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58559", "type": "HCPCS" } ], "description": "Hysteroscopy lysis", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58560", "type": "HCPCS" } ], "description": "Hysteroscopy resect septum", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58561", "type": "HCPCS" } ], "description": "Hysteroscopy remove myoma", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58562", "type": "HCPCS" } ], "description": "Hysteroscopy remove fb", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58563", "type": "HCPCS" } ], "description": "Hysteroscopy ablation", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58565", "type": "HCPCS" } ], "description": "Hysteroscopy sterilization", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58570", "type": "HCPCS" } ], "description": "Tlh uterus 250 g or less", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58571", "type": "HCPCS" } ], "description": "Tlh w/t/o 250 g or less", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58572", "type": "HCPCS" } ], "description": "Tlh uterus over 250 g", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58573", "type": "HCPCS" } ], "description": "Tlh w/t/o uterus over 250 g", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58575", "type": "HCPCS" } ], "description": "Laps tot hyst resj mal", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58578", "type": "HCPCS" } ], "description": "Laparo proc uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58579", "type": "HCPCS" } ], "description": "Hysteroscope procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58600", "type": "HCPCS" } ], "description": "Division of fallopian tube", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58605", "type": "HCPCS" } ], "description": "Division of fallopian tube", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58611", "type": "HCPCS" } ], "description": "Ligate oviduct(s) add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58615", "type": "HCPCS" } ], "description": "Occlude fallopian tube(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58660", "type": "HCPCS" } ], "description": "Laparoscopy lysis", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58661", "type": "HCPCS" } ], "description": "Laparoscopy remove adnexa", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58662", "type": "HCPCS" } ], "description": "Laparoscopy excise lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58670", "type": "HCPCS" } ], "description": "Laparoscopy tubal cautery", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58671", "type": "HCPCS" } ], "description": "Laparoscopy tubal block", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58672", "type": "HCPCS" } ], "description": "Laparoscopy fimbrioplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58673", "type": "HCPCS" } ], "description": "Laparoscopy salpingostomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58674", "type": "HCPCS" } ], "description": "Laps abltj uterine fibroids", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58679", "type": "HCPCS" } ], "description": "Laparo proc oviduct-ovary", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58700", "type": "HCPCS" } ], "description": "Removal of fallopian tube", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58720", "type": "HCPCS" } ], "description": "Removal of ovary/tube(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58740", "type": "HCPCS" } ], "description": "Adhesiolysis tube ovary", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58750", "type": "HCPCS" } ], "description": "Repair oviduct", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58752", "type": "HCPCS" } ], "description": "Revise ovarian tube(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58760", "type": "HCPCS" } ], "description": "Fimbrioplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58770", "type": "HCPCS" } ], "description": "Create new tubal opening", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58800", "type": "HCPCS" } ], "description": "Drainage of ovarian cyst(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58805", "type": "HCPCS" } ], "description": "Drainage of ovarian cyst(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58820", "type": "HCPCS" } ], "description": "Drain ovary abscess open", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58822", "type": "HCPCS" } ], "description": "Drain ovary abscess percut", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58825", "type": "HCPCS" } ], "description": "Transposition ovary(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58900", "type": "HCPCS" } ], "description": "Biopsy of ovary(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58920", "type": "HCPCS" } ], "description": "Partial removal of ovary(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 7150.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7150.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58925", "type": "HCPCS" } ], "description": "Removal of ovarian cyst(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58940", "type": "HCPCS" } ], "description": "Removal of ovary(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58943", "type": "HCPCS" } ], "description": "Removal of ovary(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58950", "type": "HCPCS" } ], "description": "Resect ovarian malignancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58951", "type": "HCPCS" } ], "description": "Resect ovarian malignancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58952", "type": "HCPCS" } ], "description": "Resect ovarian malignancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58953", "type": "HCPCS" } ], "description": "Tah rad dissect for debulk", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58954", "type": "HCPCS" } ], "description": "Tah rad debulk/lymph remove", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58956", "type": "HCPCS" } ], "description": "Bso omentectomy w/tah", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58957", "type": "HCPCS" } ], "description": "Resect Recurrent Gyn Mal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58958", "type": "HCPCS" } ], "description": "Resect Recur Gyn Mal w/Lym", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58960", "type": "HCPCS" } ], "description": "Exploration of abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58970", "type": "HCPCS" } ], "description": "Retrieval of oocyte", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58974", "type": "HCPCS" } ], "description": "Transfer of embryo", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58976", "type": "HCPCS" } ], "description": "Transfer of embryo", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "58999", "type": "HCPCS" } ], "description": "Genital surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59000", "type": "HCPCS" } ], "description": "Amniocentesis diagnostic", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59001", "type": "HCPCS" } ], "description": "Amniocentesis therapeutic", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59012", "type": "HCPCS" } ], "description": "Fetal cord puncture prenatal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59015", "type": "HCPCS" } ], "description": "Chorion biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 888.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 888.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59070", "type": "HCPCS" } ], "description": "Transabdom amnioinfus w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59072", "type": "HCPCS" } ], "description": "Umbilical cord occlud w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59074", "type": "HCPCS" } ], "description": "Fetal fluid drainage w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59076", "type": "HCPCS" } ], "description": "Fetal shunt placement w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59100", "type": "HCPCS" } ], "description": "Remove uterus lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 4823.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4823.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59120", "type": "HCPCS" } ], "description": "Treat ectopic pregnancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59121", "type": "HCPCS" } ], "description": "Treat ectopic pregnancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59130", "type": "HCPCS" } ], "description": "Treat ectopic pregnancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59136", "type": "HCPCS" } ], "description": "Treat ectopic pregnancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59140", "type": "HCPCS" } ], "description": "Treat ectopic pregnancy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59150", "type": "HCPCS" } ], "description": "Treat ectopic pregnancy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59151", "type": "HCPCS" } ], "description": "Treat ectopic pregnancy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59160", "type": "HCPCS" } ], "description": "D & c after delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59200", "type": "HCPCS" } ], "description": "Insert cervical dilator", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59300", "type": "HCPCS" } ], "description": "Episiotomy or vaginal repair", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59320", "type": "HCPCS" } ], "description": "Revision of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59325", "type": "HCPCS" } ], "description": "Revision of cervix", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59350", "type": "HCPCS" } ], "description": "Repair of uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59400", "type": "HCPCS" } ], "description": "Obstetrical care", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59409", "type": "HCPCS" } ], "description": "Obstetrical care", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59410", "type": "HCPCS" } ], "description": "Obstetrical care", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59412", "type": "HCPCS" } ], "description": "Antepartum manipulation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59414", "type": "HCPCS" } ], "description": "Deliver placenta", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59510", "type": "HCPCS" } ], "description": "Cesarean delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59514", "type": "HCPCS" } ], "description": "Cesarean delivery only", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59515", "type": "HCPCS" } ], "description": "Cesarean delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59525", "type": "HCPCS" } ], "description": "Remove uterus after cesarean", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59610", "type": "HCPCS" } ], "description": "Vbac delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59612", "type": "HCPCS" } ], "description": "Vbac delivery only", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59614", "type": "HCPCS" } ], "description": "Vbac care after delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59618", "type": "HCPCS" } ], "description": "Attempted vbac delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59620", "type": "HCPCS" } ], "description": "Attempted vbac delivery only", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59622", "type": "HCPCS" } ], "description": "Attempted vbac after care", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59812", "type": "HCPCS" } ], "description": "Treatment of miscarriage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59820", "type": "HCPCS" } ], "description": "Care of miscarriage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59821", "type": "HCPCS" } ], "description": "Treatment of miscarriage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59830", "type": "HCPCS" } ], "description": "Treat uterus infection", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59840", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59841", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59850", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59851", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59852", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59855", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59856", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59857", "type": "HCPCS" } ], "description": "Abortion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59866", "type": "HCPCS" } ], "description": "Abortion (mpr)", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59870", "type": "HCPCS" } ], "description": "Evacuate mole of uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59871", "type": "HCPCS" } ], "description": "Remove cerclage suture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59897", "type": "HCPCS" } ], "description": "Fetal invas px w/us", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59898", "type": "HCPCS" } ], "description": "Laparo proc ob care/deliver", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59899", "type": "HCPCS" } ], "description": "Maternity care procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60000", "type": "HCPCS" } ], "description": "Drain thyroid/tongue cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60100", "type": "HCPCS" } ], "description": "Biopsy of thyroid", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60200", "type": "HCPCS" } ], "description": "Remove thyroid lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60210", "type": "HCPCS" } ], "description": "Partial thyroid excision", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60212", "type": "HCPCS" } ], "description": "Partial thyroid excision", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60220", "type": "HCPCS" } ], "description": "Partial removal of thyroid", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60225", "type": "HCPCS" } ], "description": "Partial removal of thyroid", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60240", "type": "HCPCS" } ], "description": "Removal of thyroid", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60252", "type": "HCPCS" } ], "description": "Removal of thyroid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60254", "type": "HCPCS" } ], "description": "Extensive thyroid surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60260", "type": "HCPCS" } ], "description": "Repeat thyroid surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60270", "type": "HCPCS" } ], "description": "Removal of thyroid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60271", "type": "HCPCS" } ], "description": "Removal of thyroid", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60280", "type": "HCPCS" } ], "description": "Remove thyroid duct lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60281", "type": "HCPCS" } ], "description": "Remove thyroid duct lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60300", "type": "HCPCS" } ], "description": "Aspir/inj thyroid cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60500", "type": "HCPCS" } ], "description": "Explore parathyroid glands", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60502", "type": "HCPCS" } ], "description": "Re-explore parathyroids", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60505", "type": "HCPCS" } ], "description": "Explore parathyroid glands", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60520", "type": "HCPCS" } ], "description": "Removal of thymus gland", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60521", "type": "HCPCS" } ], "description": "Removal of thymus gland", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60522", "type": "HCPCS" } ], "description": "Removal of thymus gland", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60540", "type": "HCPCS" } ], "description": "Explore adrenal gland", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60545", "type": "HCPCS" } ], "description": "Explore adrenal gland", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60600", "type": "HCPCS" } ], "description": "Remove carotid body lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60605", "type": "HCPCS" } ], "description": "Remove carotid body lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60650", "type": "HCPCS" } ], "description": "Laparoscopy adrenalectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 26701.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60659", "type": "HCPCS" } ], "description": "Laparo proc endocrine", "standard_charges": [ { "billing_class": "facility", "maximum": 26701.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26701.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "60699", "type": "HCPCS" } ], "description": "Endocrine surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 5829.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5829.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61000", "type": "HCPCS" } ], "description": "Remove cranial cavity fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61001", "type": "HCPCS" } ], "description": "Remove cranial cavity fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61020", "type": "HCPCS" } ], "description": "Remove brain cavity fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61026", "type": "HCPCS" } ], "description": "Injection into brain canal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61050", "type": "HCPCS" } ], "description": "Remove brain canal fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61055", "type": "HCPCS" } ], "description": "Injection into brain canal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61070", "type": "HCPCS" } ], "description": "Brain canal shunt procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61105", "type": "HCPCS" } ], "description": "Twist drill hole", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61107", "type": "HCPCS" } ], "description": "Drill skull for implantation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61108", "type": "HCPCS" } ], "description": "Drill skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61120", "type": "HCPCS" } ], "description": "Burr hole for puncture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61140", "type": "HCPCS" } ], "description": "Pierce skull for biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61150", "type": "HCPCS" } ], "description": "Pierce skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61151", "type": "HCPCS" } ], "description": "Pierce skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61154", "type": "HCPCS" } ], "description": "Pierce skull & remove clot", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61156", "type": "HCPCS" } ], "description": "Pierce skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61210", "type": "HCPCS" } ], "description": "Pierce skull implant device", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61215", "type": "HCPCS" } ], "description": "Insert brain-fluid device", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61250", "type": "HCPCS" } ], "description": "Pierce skull & explore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61253", "type": "HCPCS" } ], "description": "Pierce skull & explore", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61304", "type": "HCPCS" } ], "description": "Open skull for exploration", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61305", "type": "HCPCS" } ], "description": "Open skull for exploration", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61312", "type": "HCPCS" } ], "description": "Open skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61313", "type": "HCPCS" } ], "description": "Open skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61314", "type": "HCPCS" } ], "description": "Open skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61315", "type": "HCPCS" } ], "description": "Open skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61316", "type": "HCPCS" } ], "description": "Implt cran bone flap to abdo", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61320", "type": "HCPCS" } ], "description": "Open skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61321", "type": "HCPCS" } ], "description": "Open skull for drainage", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61322", "type": "HCPCS" } ], "description": "Decompressive craniotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61323", "type": "HCPCS" } ], "description": "Decompressive lobectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61330", "type": "HCPCS" } ], "description": "Decompress eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61333", "type": "HCPCS" } ], "description": "Explore orbit/remove lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61340", "type": "HCPCS" } ], "description": "Subtemporal decompression", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61343", "type": "HCPCS" } ], "description": "Incise skull (press relief)", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61345", "type": "HCPCS" } ], "description": "Relieve cranial pressure", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61450", "type": "HCPCS" } ], "description": "Incise skull for surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61458", "type": "HCPCS" } ], "description": "Incise skull for brain wound", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61460", "type": "HCPCS" } ], "description": "Incise skull for surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61500", "type": "HCPCS" } ], "description": "Removal of skull lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61501", "type": "HCPCS" } ], "description": "Remove infected skull bone", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61510", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61512", "type": "HCPCS" } ], "description": "Remove brain lining lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61514", "type": "HCPCS" } ], "description": "Removal of brain abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61516", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61517", "type": "HCPCS" } ], "description": "Implt brain chemotx add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61518", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61519", "type": "HCPCS" } ], "description": "Remove brain lining lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61520", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61521", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61522", "type": "HCPCS" } ], "description": "Removal of brain abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61524", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61526", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61530", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61531", "type": "HCPCS" } ], "description": "Implant brain electrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61533", "type": "HCPCS" } ], "description": "Implant brain electrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61534", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61535", "type": "HCPCS" } ], "description": "Remove brain electrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61536", "type": "HCPCS" } ], "description": "Removal of brain lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61537", "type": "HCPCS" } ], "description": "Removal of brain tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61538", "type": "HCPCS" } ], "description": "Removal of brain tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61539", "type": "HCPCS" } ], "description": "Removal of brain tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61540", "type": "HCPCS" } ], "description": "Removal of brain tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61541", "type": "HCPCS" } ], 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"plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61545", "type": "HCPCS" } ], "description": "Excision of brain tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61546", "type": "HCPCS" } ], "description": "Removal of pituitary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61548", "type": "HCPCS" } ], "description": "Removal of pituitary gland", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61550", "type": "HCPCS" } ], "description": "Release of skull seams", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61552", "type": "HCPCS" } ], "description": "Release of skull seams", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61556", "type": "HCPCS" } ], "description": "Incise skull/sutures", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61557", "type": "HCPCS" } ], "description": "Incise skull/sutures", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61558", "type": "HCPCS" } ], "description": "Excision of skull/sutures", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61559", "type": "HCPCS" } ], "description": "Excision of skull/sutures", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61563", "type": "HCPCS" } ], "description": "Excision of skull tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61564", "type": "HCPCS" } ], "description": "Excision of skull tumor", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61566", "type": "HCPCS" } ], "description": "Removal of brain tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61567", "type": "HCPCS" } ], "description": "Incision of brain tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61570", "type": "HCPCS" } ], "description": "Remove foreign body brain", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61571", "type": "HCPCS" } ], "description": "Incise skull for brain wound", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61575", "type": "HCPCS" } ], "description": "Skull base/brainstem surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61576", "type": "HCPCS" } ], "description": "Skull base/brainstem surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61580", "type": "HCPCS" } ], "description": "Craniofacial approach skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61581", "type": "HCPCS" } ], "description": "Craniofacial approach skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61582", "type": "HCPCS" } ], "description": "Craniofacial approach skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61583", "type": "HCPCS" } ], "description": "Craniofacial approach skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61584", "type": "HCPCS" } ], "description": "Orbitocranial approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61585", "type": "HCPCS" } ], "description": "Orbitocranial approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61586", "type": "HCPCS" } ], "description": "Resect nasopharynx skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61590", "type": "HCPCS" } ], "description": "Infratemporal approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61591", "type": "HCPCS" } ], "description": "Infratemporal approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61592", "type": "HCPCS" } ], "description": "Orbitocranial approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61595", "type": "HCPCS" } ], "description": "Transtemporal approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61596", "type": "HCPCS" } ], "description": "Transcochlear approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61597", "type": "HCPCS" } ], "description": "Transcondylar approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61598", "type": "HCPCS" } ], "description": "Transpetrosal approach/skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61600", "type": "HCPCS" } ], "description": "Resect/excise cranial lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61601", "type": "HCPCS" } ], "description": "Resect/excise cranial lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61605", "type": "HCPCS" } ], "description": "Resect/excise cranial lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61606", "type": "HCPCS" } ], "description": "Resect/excise cranial lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61607", "type": "HCPCS" } ], "description": "Resect/excise cranial lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61608", "type": "HCPCS" } ], "description": "Resect/excise cranial lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61611", "type": "HCPCS" } ], "description": "Transect artery sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61613", "type": "HCPCS" } ], "description": "Remove aneurysm sinus", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61615", "type": "HCPCS" } ], "description": "Resect/excise lesion skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61616", "type": "HCPCS" } ], "description": "Resect/excise lesion skull", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61618", "type": "HCPCS" } ], "description": "Repair dura", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61619", "type": "HCPCS" } ], "description": "Repair dura", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61623", "type": "HCPCS" } ], "description": "Endovasc tempory vessel occl", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61624", "type": "HCPCS" } ], "description": "Transcath occlusion cns", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61626", "type": "HCPCS" } ], "description": "Transcath occlusion non-cns", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61630", "type": "HCPCS" } ], "description": "Intracranial angioplasty", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61635", "type": "HCPCS" } ], "description": "Intracran angioplsty w/stent", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61640", "type": "HCPCS" } ], "description": "Dilate ic vasospasm init", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61641", "type": "HCPCS" } ], "description": "Dilate ic vasospasm add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61642", "type": "HCPCS" } ], "description": "Dilate ic vasospasm add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61645", "type": "HCPCS" } ], "description": "Perq art m-thrombect &/nfs", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61650", "type": "HCPCS" } ], "description": "Evasc prlng admn rx agnt 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61651", "type": "HCPCS" } ], "description": "Evasc prlng admn rx agnt add", "standard_charges": [ { "billing_class": "facility", "maximum": 30765.0, "minimum": 30765.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30765.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61680", "type": "HCPCS" } ], "description": "Intracranial vessel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61682", "type": "HCPCS" } ], "description": "Intracranial vessel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61684", "type": "HCPCS" } ], "description": "Intracranial vessel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61686", "type": "HCPCS" } ], "description": "Intracranial vessel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61690", "type": "HCPCS" } ], "description": "Intracranial vessel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61692", "type": "HCPCS" } ], "description": "Intracranial vessel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61697", "type": "HCPCS" } ], "description": "Brain aneurysm repr complx", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61698", "type": "HCPCS" } ], "description": "Brain aneurysm repr complx", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61700", "type": "HCPCS" } ], "description": "Brain aneurysm repr simple", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61702", "type": "HCPCS" } ], "description": "Inner skull vessel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61703", "type": "HCPCS" } ], "description": "Clamp neck artery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61705", "type": "HCPCS" } ], "description": "Revise circulation to head", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61708", "type": "HCPCS" } ], "description": "Revise circulation to head", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61710", "type": "HCPCS" } ], "description": "Revise circulation to head", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61711", "type": "HCPCS" } ], "description": "Fusion of skull arteries", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61720", "type": "HCPCS" } ], "description": "Incise skull/brain surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61735", "type": "HCPCS" } ], "description": "Incise skull/brain surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61736", "type": "HCPCS" } ], "description": "Litt icr 1 traj 1 smpl les", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61737", "type": "HCPCS" } ], "description": "Litt icr mlt trj mlt/cplx ls", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61750", "type": "HCPCS" } ], "description": "Incise skull/brain biopsy", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61751", "type": "HCPCS" } ], "description": "Brain biopsy w/ct/mr guide", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61760", "type": "HCPCS" } ], "description": "Implant brain electrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61770", "type": "HCPCS" } ], "description": "Incise skull for treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61790", "type": "HCPCS" } ], "description": "Treat trigeminal nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61791", "type": "HCPCS" } ], "description": "Treat trigeminal tract", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61796", "type": "HCPCS" } ], "description": "Srs cranial lesion simple", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61797", "type": "HCPCS" } ], "description": "Srs cran les simple addl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61798", "type": "HCPCS" } ], "description": "Srs cranial lesion complex", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61799", "type": "HCPCS" } ], "description": "Srs cran les complex addl", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 16564.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61800", "type": "HCPCS" } ], "description": "Apply srs headframe add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 3714.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61850", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61860", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61863", "type": "HCPCS" } ], "description": "Implant neuroelectrode", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61864", "type": "HCPCS" } ], "description": "Implant neuroelectrde addl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61867", "type": "HCPCS" } ], "description": "Implant neuroelectrode", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61868", "type": "HCPCS" } ], "description": "Implant neuroelectrde addl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61880", "type": "HCPCS" } ], "description": "Revise/remove neuroelectrode", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61885", "type": "HCPCS" } ], "description": "Insrt/redo neurostim 1 array", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61886", "type": "HCPCS" } ], "description": "Implant neurostim arrays", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "61888", "type": "HCPCS" } ], "description": "Revise/remove neuroreceiver", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62000", "type": "HCPCS" } ], "description": "Treat skull fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62005", "type": "HCPCS" } ], "description": "Treat skull fracture", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62010", "type": "HCPCS" } ], "description": "Treatment of head injury", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62100", "type": "HCPCS" } ], "description": "Repair brain fluid leakage", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62115", "type": "HCPCS" } ], "description": "Reduction of skull defect", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62117", "type": "HCPCS" } ], "description": "Reduction of skull defect", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62120", "type": "HCPCS" } ], "description": "Repair skull cavity lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62121", "type": "HCPCS" } ], "description": "Incise skull repair", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62140", "type": "HCPCS" } ], "description": "Repair of skull defect", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62141", "type": "HCPCS" } ], "description": "Repair of skull defect", 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"standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62145", "type": "HCPCS" } ], "description": "Repair of skull & brain", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62146", "type": "HCPCS" } ], "description": "Repair of skull with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62147", "type": "HCPCS" } ], "description": "Repair of skull with graft", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62148", "type": "HCPCS" } ], "description": "Retr bone flap to fix skull", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62161", "type": "HCPCS" } ], "description": "Dissect brain w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62162", "type": "HCPCS" } ], "description": "Remove colloid cyst w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62164", "type": "HCPCS" } ], "description": "Remove brain tumor w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62165", "type": "HCPCS" } ], "description": "Remove pituit tumor w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62180", "type": "HCPCS" } ], "description": "Establish brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62190", "type": "HCPCS" } ], "description": "Establish brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62192", "type": "HCPCS" } ], "description": "Establish brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62194", "type": "HCPCS" } ], "description": "Replace/irrigate catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62200", "type": "HCPCS" } ], "description": "Establish brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62201", "type": "HCPCS" } ], "description": "Brain cavity shunt w/scope", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62220", "type": "HCPCS" } ], "description": "Establish brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62223", "type": "HCPCS" } ], "description": "Establish brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62225", "type": "HCPCS" } ], "description": "Replace/irrigate catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62230", "type": "HCPCS" } ], "description": "Replace/revise brain shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62252", "type": "HCPCS" } ], "description": "Csf Shunt Reprogram", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 296.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 296.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62256", "type": "HCPCS" } ], "description": "Remove brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62258", "type": "HCPCS" } ], "description": "Replace brain cavity shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62263", "type": "HCPCS" } ], "description": "Epidural lysis mult sessions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62264", "type": "HCPCS" } ], "description": "Epidural lysis on single day", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62267", "type": "HCPCS" } ], "description": "Interdiscal perq aspir dx", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62268", "type": "HCPCS" } ], "description": "Drain spinal cord cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62269", "type": "HCPCS" } ], "description": "Needle biopsy spinal cord", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62270", "type": "HCPCS" } ], "description": "Spinal fluid tap diagnostic", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62272", "type": "HCPCS" } ], "description": "Drain cerebro spinal fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62273", "type": "HCPCS" } ], "description": "Inject epidural patch", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62280", "type": "HCPCS" } ], "description": "Treat spinal cord lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62281", "type": "HCPCS" } ], "description": "Treat spinal cord lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62282", "type": "HCPCS" } ], "description": "Treat spinal canal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62287", "type": "HCPCS" } ], "description": "Percutaneous diskectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62292", "type": "HCPCS" } ], "description": "Injection into disk lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62294", "type": "HCPCS" } ], "description": "Injection into spinal artery", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62302", "type": "HCPCS" } ], "description": "Myelography lumbar injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62303", "type": "HCPCS" } ], "description": "Myelography lumbar injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62304", "type": "HCPCS" } ], "description": "Myelography lumbar injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62305", "type": "HCPCS" } ], "description": "Myelography lumbar injection", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62320", "type": "HCPCS" } ], "description": "Njx interlaminar crv/thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62321", "type": "HCPCS" } ], "description": "Njx interlaminar crv/thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62322", "type": "HCPCS" } ], "description": "Njx interlaminar lmbr/sac", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62323", "type": "HCPCS" } ], "description": "Njx interlaminar lmbr/sac", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62324", "type": "HCPCS" } ], "description": "Njx interlaminar crv/thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62325", "type": "HCPCS" } ], "description": "Njx interlaminar crv/thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62326", "type": "HCPCS" } ], "description": "Njx interlaminar lmbr/sac", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62327", "type": "HCPCS" } ], "description": "Njx interlaminar lmbr/sac", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62328", "type": "HCPCS" } ], "description": "Dx lmbr spi pnxr w/fluor/ct", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62329", "type": "HCPCS" } ], "description": "Ther spi pnxr csf fluor/ct", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62350", "type": "HCPCS" } ], "description": "Implant spinal canal cath", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62351", "type": "HCPCS" } ], "description": "Implant spinal canal cath", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62355", "type": "HCPCS" } ], "description": "Remove spinal canal catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62360", "type": "HCPCS" } ], "description": "Insert spine infusion device", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17378.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17378.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62361", "type": "HCPCS" } ], "description": "Implant spine infusion pump", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17378.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17378.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62362", "type": "HCPCS" } ], "description": "Implant spine infusion pump", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 17378.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17378.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62365", "type": "HCPCS" } ], "description": "Remove spine infusion device", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62367", "type": "HCPCS" } ], "description": "Analyze spine infus pump", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 296.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 296.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62368", "type": "HCPCS" } ], "description": "Analyze sp inf pump w/reprog", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 296.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 296.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62369", "type": "HCPCS" } ], "description": "Anal sp inf pmp w/reprg&fill", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 296.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 296.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62370", "type": "HCPCS" } ], "description": "Anl sp inf pmp w/mdreprg&fil", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 296.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 296.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62380", "type": "HCPCS" } ], "description": "Ndsc dcmprn 1 ntrspc lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63001", "type": "HCPCS" } ], "description": "Remove spine lamina 1/2 crvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63003", "type": "HCPCS" } ], "description": "Remove spine lamina 1/2 thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63005", "type": "HCPCS" } ], "description": "Remove spine lamina 1/2 lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63011", "type": "HCPCS" } ], "description": "Remove spine lamina 1/2 scrl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63012", "type": "HCPCS" } ], "description": "Remove lamina/facets lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63015", "type": "HCPCS" } ], "description": "Remove spine lamina >2 crvcl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63016", "type": "HCPCS" } ], "description": "Remove spine lamina >2 thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63017", "type": "HCPCS" } ], "description": "Remove spine lamina >2 lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63020", "type": "HCPCS" } ], "description": "Neck spine disk surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63030", "type": "HCPCS" } ], "description": "Low back disk surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63040", "type": "HCPCS" } ], "description": "Laminotomy single cervical", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63042", "type": "HCPCS" } ], "description": "Laminotomy single lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63045", "type": "HCPCS" } ], "description": "Remove spine lamina 1 crvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63046", "type": "HCPCS" } ], "description": "Remove spine lamina 1 thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63047", "type": "HCPCS" } ], "description": "Remove spine lamina 1 lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63050", "type": "HCPCS" } ], "description": "Cervical laminoplsty 2/> seg", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63051", "type": "HCPCS" } ], "description": "C-laminoplasty w/graft/plate", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63055", "type": "HCPCS" } ], "description": "Decompress spinal cord thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63056", "type": "HCPCS" } ], "description": "Decompress spinal cord lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63064", "type": "HCPCS" } ], "description": "Decompress spinal cord thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63075", "type": "HCPCS" } ], "description": "Neck spine disk surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63077", "type": "HCPCS" } ], "description": "Spine disk surgery thorax", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63078", "type": "HCPCS" } ], "description": "Spine disk surgery thorax", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63081", "type": "HCPCS" } ], "description": "Remove vert body dcmprn crvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63082", "type": "HCPCS" } ], "description": "Remove vertebral body add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63085", "type": "HCPCS" } ], "description": "Remove vert body dcmprn thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63086", "type": "HCPCS" } ], "description": "Remove vertebral body add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63087", "type": "HCPCS" } ], "description": "Remov vertbr dcmprn thrclmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63088", "type": "HCPCS" } ], "description": "Remove vertebral body add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63090", "type": "HCPCS" } ], "description": "Remove vert body dcmprn lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63091", "type": "HCPCS" } ], "description": "Remove vertebral body add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63101", "type": "HCPCS" } ], "description": "Remove vert body dcmprn thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63102", "type": "HCPCS" } ], "description": "Remove vert body dcmprn lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63103", "type": "HCPCS" } ], "description": "Remove vertebral body add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63170", "type": "HCPCS" } ], "description": "Incise spinal cord tract(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63172", "type": "HCPCS" } ], "description": "Drainage of spinal cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63173", "type": "HCPCS" } ], "description": "Drainage of spinal cyst", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63185", "type": "HCPCS" } ], "description": "Incise spine nrv half segmnt", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63190", "type": "HCPCS" } ], "description": "Incise spine nrv >2 segmnts", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63191", "type": "HCPCS" } ], "description": "Incise spine accessory nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63197", "type": "HCPCS" } ], "description": "Incise spine&cord 2 trx thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63200", "type": "HCPCS" } ], "description": "Release spinal cord lumbar", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63250", "type": "HCPCS" } ], "description": "Revise spinal cord vsls crvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63251", "type": "HCPCS" } ], "description": "Revise spinal cord vsls thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63252", "type": "HCPCS" } ], "description": "Revise spine cord vsl thrlmb", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63265", "type": "HCPCS" } ], "description": "Excise intraspinl lesion crv", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63266", "type": "HCPCS" } ], "description": "Excise intrspinl lesion thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63267", "type": "HCPCS" } ], "description": "Excise intrspinl lesion lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63268", "type": "HCPCS" } ], "description": "Excise intrspinl lesion scrl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63270", "type": "HCPCS" } ], "description": "Excise intrspinl lesion crvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63271", "type": "HCPCS" } ], "description": "Excise intrspinl lesion thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63272", "type": "HCPCS" } ], "description": "Excise intrspinl lesion lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63273", "type": "HCPCS" } ], "description": "Excise intrspinl lesion scrl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63275", "type": "HCPCS" } ], "description": "Bx/exc xdrl spine lesn crvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63276", "type": "HCPCS" } ], "description": "Bx/exc xdrl spine lesn thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63277", "type": "HCPCS" } ], "description": "Bx/exc xdrl spine lesn lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63278", "type": "HCPCS" } ], "description": "Bx/exc xdrl spine lesn scrl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63280", "type": "HCPCS" } ], "description": "Bx/exc idrl spine lesn crvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63281", "type": "HCPCS" } ], "description": "Bx/exc idrl spine lesn thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63282", "type": "HCPCS" } ], "description": "Bx/exc idrl spine lesn lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63283", "type": "HCPCS" } ], "description": "Bx/exc idrl spine lesn scrl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63285", "type": "HCPCS" } ], "description": "Bx/exc idrl imed lesn cervl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63286", "type": "HCPCS" } ], "description": "Bx/exc idrl imed lesn thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63287", "type": "HCPCS" } ], "description": "Bx/exc idrl imed lesn thrlmb", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63290", "type": "HCPCS" } ], "description": "Bx/exc xdrl/idrl lsn any lvl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63295", "type": "HCPCS" } ], "description": "Repair laminectomy defect", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63300", "type": "HCPCS" } ], "description": "Remove vert xdrl body crvcl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63301", "type": "HCPCS" } ], "description": "Remove vert xdrl body thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63302", "type": "HCPCS" } ], "description": "Remove vert xdrl body thrlmb", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63303", "type": "HCPCS" } ], "description": "Remov vert xdrl bdy lmbr/sac", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63304", "type": "HCPCS" } ], "description": "Remove vert idrl body crvcl", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63305", "type": "HCPCS" } ], "description": "Remove vert idrl body thrc", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63306", "type": "HCPCS" } ], "description": "Remov vert idrl bdy thrclmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63307", "type": "HCPCS" } ], "description": "Remov vert idrl bdy lmbr/sac", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63308", "type": "HCPCS" } ], "description": "Remove vertebral body add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63600", "type": "HCPCS" } ], "description": "Remove spinal cord lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63610", "type": "HCPCS" } ], "description": "Stimulation of spinal cord", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63620", "type": "HCPCS" } ], "description": "Srs spinal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63621", "type": "HCPCS" } ], "description": "Srs spinal lesion addl", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63650", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 6144.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6144.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63655", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18706.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18706.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63661", "type": "HCPCS" } ], "description": "Remove spine eltrd perq aray", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63662", "type": "HCPCS" } ], "description": "Remove spine eltrd plate", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63663", "type": "HCPCS" } ], "description": "Revise spine eltrd perq aray", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 6144.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6144.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63664", "type": "HCPCS" } ], "description": "Revise spine eltrd plate", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63685", "type": "HCPCS" } ], "description": "Insrt/redo spine n generator", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63688", "type": "HCPCS" } ], "description": "Revise/remove neuroreceiver", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63700", "type": "HCPCS" } ], "description": "Repair of spinal herniation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63702", "type": "HCPCS" } ], "description": "Repair of spinal herniation", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63704", "type": "HCPCS" } ], "description": "Repair of spinal herniation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63706", "type": "HCPCS" } ], "description": "Repair of spinal herniation", "standard_charges": [ { "billing_class": "facility", "maximum": 31685.0, "minimum": 31685.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31685.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63707", "type": "HCPCS" } ], "description": "Repair spinal fluid leakage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63709", "type": "HCPCS" } ], "description": "Repair spinal fluid leakage", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63710", "type": "HCPCS" } ], "description": "Graft repair of spine defect", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63740", "type": "HCPCS" } ], "description": "Install spinal shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63741", "type": "HCPCS" } ], "description": "Install spinal shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63744", "type": "HCPCS" } ], "description": "Revision of spinal shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "63746", "type": "HCPCS" } ], "description": "Removal of spinal shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64400", "type": "HCPCS" } ], "description": "N block inj trigeminal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64405", "type": "HCPCS" } ], "description": "N block inj occipital", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64408", "type": "HCPCS" } ], "description": "N block inj vagus", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64415", "type": "HCPCS" } ], "description": "N block inj brachial plexus", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64416", "type": "HCPCS" } ], "description": "N block cont infuse b plex", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64417", "type": "HCPCS" } ], "description": "N block inj axillary", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64418", "type": "HCPCS" } ], "description": "N block inj suprascapular", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64420", "type": "HCPCS" } ], "description": "N block inj intercost sng", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64421", "type": "HCPCS" } ], "description": "N block inj intercost mlt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64425", "type": "HCPCS" } ], "description": "N block inj ilio-ing/hypogi", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64430", "type": "HCPCS" } ], "description": "N block inj pudendal", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64435", "type": "HCPCS" } ], "description": "N block inj paracervical", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64445", "type": "HCPCS" } ], "description": "N block inj sciatic sng", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64446", "type": "HCPCS" } ], "description": "N blk inj sciatic cont inf", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64447", "type": "HCPCS" } ], "description": "N block inj fem single", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64448", "type": "HCPCS" } ], "description": "N block inj fem cont inf", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64449", "type": "HCPCS" } ], "description": "N block inj lumbar plexus", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64450", "type": "HCPCS" } ], "description": "N block other peripheral", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64451", "type": "HCPCS" } ], "description": "Njx aa&/strd nrv nrvtg si jt", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64454", "type": "HCPCS" } ], "description": "Njx aa&/strd gnclr nrv brnch", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64455", "type": "HCPCS" } ], "description": "N block inj plantar digit", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64461", "type": "HCPCS" } ], "description": "Pvb thoracic single inj site", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64463", "type": "HCPCS" } ], "description": "Pvb thoracic cont infusion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64479", "type": "HCPCS" } ], "description": "Inj foramen epidural c/t", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64483", "type": "HCPCS" } ], "description": "Inj foramen epidural l/s", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64490", "type": "HCPCS" } ], "description": "Inj paravert f jnt c/t 1 lev", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64493", "type": "HCPCS" } ], "description": "Inj paravert f jnt l/s 1 lev", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64505", "type": "HCPCS" } ], "description": "N block spenopalatine gangl", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64510", "type": "HCPCS" } ], "description": "N block stellate ganglion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64517", "type": "HCPCS" } ], "description": "N block inj hypogas plxs", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64520", "type": "HCPCS" } ], "description": "N block lumbar/thoracic", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64530", "type": "HCPCS" } ], "description": "N block inj celiac pelus", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64553", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64555", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 6144.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6144.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64561", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 6144.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6144.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64566", "type": "HCPCS" } ], "description": "Neuroeltrd stim post tibial", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64568", "type": "HCPCS" } ], "description": "Inc for vagus n elect impl", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 42470.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42470.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64569", "type": "HCPCS" } ], "description": "Revise/repl vagus n eltrd", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64570", "type": "HCPCS" } ], "description": "Remove vagus n eltrd", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64575", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64580", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18706.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18706.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64581", "type": "HCPCS" } ], "description": "Implant neuroelectrodes", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 6144.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6144.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64582", "type": "HCPCS" } ], "description": "Opn mpltj hpglsl nstm ary pg", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64583", "type": "HCPCS" } ], "description": "Rev/rplct hpglsl nstm ary pg", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64584", "type": "HCPCS" } ], "description": "Rmvl hpglsl nstim ary pg", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64585", "type": "HCPCS" } ], "description": "Revise/remove neuroelectrode", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64590", "type": "HCPCS" } ], "description": "Insrt/redo pn/gastr stimul", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 18706.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18706.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64595", "type": "HCPCS" } ], "description": "Revise/rmv pn/gastr stimul", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64600", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64605", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64610", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64611", "type": "HCPCS" } ], "description": "Chemodenerv saliv glands", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64612", "type": "HCPCS" } ], "description": "Destroy nerve face muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64615", "type": "HCPCS" } ], "description": "Chemodenerv musc migraine", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64616", "type": "HCPCS" } ], "description": "Chemodenerv musc neck dyston", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64617", "type": "HCPCS" } ], "description": "Chemodener muscle larynx emg", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64620", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64624", "type": "HCPCS" } ], "description": "Dstrj nulyt agt gnclr nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64625", "type": "HCPCS" } ], "description": "Rf abltj nrv nrvtg si jt", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64628", "type": "HCPCS" } ], "description": "Trml dstrj ios bvn 1st 2 l/s", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64630", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64632", "type": "HCPCS" } ], "description": "N block inj common digit", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64633", "type": "HCPCS" } ], "description": "Destroy cerv/thor facet jnt", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64635", "type": "HCPCS" } ], "description": "Destroy lumb/sac facet jnt", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64640", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64642", "type": "HCPCS" } ], "description": "Chemodenerv 1 extremity 1-4", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64644", "type": "HCPCS" } ], "description": "Chemodenerv 1 extrem 5/> mus", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64646", "type": "HCPCS" } ], "description": "Chemodenerv trunk musc 1-5", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64647", "type": "HCPCS" } ], "description": "Chemodenerv trunk musc 6/>", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 680.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64650", "type": "HCPCS" } ], "description": "Chemodenerv eccrine glands", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64653", "type": "HCPCS" } ], "description": "Chemodenerv eccrine glands", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64680", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64681", "type": "HCPCS" } ], "description": "Injection treatment of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 852.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 852.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64702", "type": "HCPCS" } ], "description": "Revise finger/toe nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64704", "type": "HCPCS" } ], "description": "Revise hand/foot nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64708", "type": "HCPCS" } ], "description": "Revise arm/leg nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64712", "type": "HCPCS" } ], "description": "Revision of sciatic nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64713", "type": "HCPCS" } ], "description": "Revision of arm nerve(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64714", "type": "HCPCS" } ], "description": "Revise low back nerve(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64716", "type": "HCPCS" } ], "description": "Revision of cranial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64718", "type": "HCPCS" } ], "description": "Revise ulnar nerve at elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64719", "type": "HCPCS" } ], "description": "Revise ulnar nerve at wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64721", "type": "HCPCS" } ], "description": "Carpal tunnel surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64722", "type": "HCPCS" } ], "description": "Relieve pressure on nerve(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64726", "type": "HCPCS" } ], "description": "Release foot/toe nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64732", "type": "HCPCS" } ], "description": "Incision of brow nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64734", "type": "HCPCS" } ], "description": "Incision of cheek nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64736", "type": "HCPCS" } ], "description": "Incision of chin nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64738", "type": "HCPCS" } ], "description": "Incision of jaw nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64740", "type": "HCPCS" } ], "description": "Incision of tongue nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64742", "type": "HCPCS" } ], "description": "Incision of facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64744", "type": "HCPCS" } ], "description": "Incise nerve back of head", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64746", "type": "HCPCS" } ], "description": "Incise diaphragm nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64755", "type": "HCPCS" } ], "description": "Incision of stomach nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64760", "type": "HCPCS" } ], "description": "Incision of vagus nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64763", "type": "HCPCS" } ], "description": "Incise hip/thigh nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64766", "type": "HCPCS" } ], "description": "Incise hip/thigh nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64771", "type": "HCPCS" } ], "description": "Sever cranial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64772", "type": "HCPCS" } ], "description": "Incision of spinal nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64774", "type": "HCPCS" } ], "description": "Remove skin nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64776", "type": "HCPCS" } ], "description": "Remove digit nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64782", "type": "HCPCS" } ], "description": "Remove limb nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64784", "type": "HCPCS" } ], "description": "Remove nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64786", "type": "HCPCS" } ], "description": "Remove sciatic nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64788", "type": "HCPCS" } ], "description": "Remove skin nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64790", "type": "HCPCS" } ], "description": "Removal of nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64792", "type": "HCPCS" } ], "description": "Removal of nerve lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64795", "type": "HCPCS" } ], "description": "Biopsy of nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64802", "type": "HCPCS" } ], "description": "Sympathectomy cervical", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64804", "type": "HCPCS" } ], "description": "Remove sympathetic nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64809", "type": "HCPCS" } ], "description": "Remove sympathetic nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64818", "type": "HCPCS" } ], "description": "Remove sympathetic nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64820", "type": "HCPCS" } ], "description": "Sympathectomy digital artery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64821", "type": "HCPCS" } ], "description": "Remove sympathetic nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64822", "type": "HCPCS" } ], "description": "Remove sympathetic nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64823", "type": "HCPCS" } ], "description": "Sympathectomy supfc palmar", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64831", "type": "HCPCS" } ], "description": "Repair of digit nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64834", "type": "HCPCS" } ], "description": "Repair of hand or foot nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64835", "type": "HCPCS" } ], "description": "Repair of hand or foot nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64836", "type": "HCPCS" } ], "description": "Repair of hand or foot nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64840", "type": "HCPCS" } ], "description": "Repair of leg nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64856", "type": "HCPCS" } ], "description": "Repair/transpose nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64857", "type": "HCPCS" } ], "description": "Repair arm/leg nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64858", "type": "HCPCS" } ], "description": "Repair sciatic nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64861", "type": "HCPCS" } ], "description": "Repair of arm nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64862", "type": "HCPCS" } ], "description": "Repair of low back nerves", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64864", "type": "HCPCS" } ], "description": "Repair of facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64865", "type": "HCPCS" } ], "description": "Repair of facial nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64866", "type": "HCPCS" } ], "description": "Fusion of facial/other nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64868", "type": "HCPCS" } ], "description": "Fusion of facial/other nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 20001.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64885", "type": "HCPCS" } ], "description": "Nerve graft head/neck <=4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64886", "type": "HCPCS" } ], "description": "Nerve graft head/neck >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64890", "type": "HCPCS" } ], "description": "Nerve graft hand/foot <=4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64891", "type": "HCPCS" } ], "description": "Nerve graft hand/foot >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64892", "type": "HCPCS" } ], "description": "Nerve graft arm/leg <4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64893", "type": "HCPCS" } ], "description": "Nerve graft arm/leg >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64895", "type": "HCPCS" } ], "description": "Nerve graft hand/foot <=4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64896", "type": "HCPCS" } ], "description": "Nerve graft hand/foot >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64897", "type": "HCPCS" } ], "description": "Nerve graft arm/leg <=4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64898", "type": "HCPCS" } ], "description": "Nerve graft arm/leg >4 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64905", "type": "HCPCS" } ], "description": "Nerve pedicle transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64907", "type": "HCPCS" } ], "description": "Nerve pedicle transfer", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64910", "type": "HCPCS" } ], "description": "Nerve repair w/allograft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64911", "type": "HCPCS" } ], "description": "Neurorraphy w/vein autograft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64912", "type": "HCPCS" } ], "description": "Nrv rpr w/nrv algrft 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 8461.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8461.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64999", "type": "HCPCS" } ], "description": "Nervous system surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65091", "type": "HCPCS" } ], "description": "Revise eye", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65093", "type": "HCPCS" } ], "description": "Revise eye with implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65101", "type": "HCPCS" } ], "description": "Removal of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65103", "type": "HCPCS" } ], "description": "Remove eye/insert implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65105", "type": "HCPCS" } ], "description": "Remove eye/attach implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65110", "type": "HCPCS" } ], "description": "Removal of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65112", "type": "HCPCS" } ], "description": "Remove eye/revise socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65114", "type": "HCPCS" } ], "description": "Remove eye/revise socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65125", "type": "HCPCS" } ], "description": "Revise ocular implant", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65130", "type": "HCPCS" } ], "description": "Insert ocular implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65135", "type": "HCPCS" } ], "description": "Insert ocular implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65140", "type": "HCPCS" } ], "description": "Attach ocular implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65150", "type": "HCPCS" } ], "description": "Revise ocular implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65155", "type": 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"standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65205", "type": "HCPCS" } ], "description": "Remove foreign body from eye", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65210", "type": "HCPCS" } ], "description": "Remove foreign body from eye", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65220", "type": "HCPCS" } ], "description": "Remove foreign body from eye", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65222", "type": "HCPCS" } ], "description": "Remove foreign body from eye", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { 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eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65265", "type": "HCPCS" } ], "description": "Remove foreign body from eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65270", "type": "HCPCS" } ], "description": "Repair of eye wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65272", "type": "HCPCS" } ], "description": "Repair of eye wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65273", "type": "HCPCS" } ], "description": "Repair of eye wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 9206.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65275", "type": "HCPCS" } ], "description": "Repair of eye wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65280", "type": "HCPCS" } ], "description": "Repair of eye wound", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65285", "type": "HCPCS" } ], "description": "Repair of eye wound", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65286", "type": "HCPCS" } ], "description": "Repair of eye wound", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65290", "type": "HCPCS" } ], "description": "Repair of eye socket wound", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { 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} ] }, { "code_information": [ { "code": "65426", "type": "HCPCS" } ], "description": "Removal of eye lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65430", "type": "HCPCS" } ], "description": "Corneal smear", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65435", "type": "HCPCS" } ], "description": "Curette/treat cornea", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65436", "type": "HCPCS" } ], "description": "Curette/treat cornea", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65450", "type": "HCPCS" } ], "description": "Treatment of corneal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65600", "type": "HCPCS" } ], "description": "Revision of cornea", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65710", "type": "HCPCS" } ], "description": "Corneal transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65730", "type": "HCPCS" } ], "description": "Corneal transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65750", "type": "HCPCS" } ], "description": "Corneal transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65755", "type": "HCPCS" } ], "description": "Corneal transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65756", "type": "HCPCS" } ], "description": "Corneal trnspl endothelial", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65760", "type": "HCPCS" } ], "description": "Revision of cornea", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65765", "type": "HCPCS" } ], "description": "Revision of cornea", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65767", "type": "HCPCS" } ], "description": "Corneal tissue transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65770", "type": "HCPCS" } ], "description": "Revise cornea with implant", "standard_charges": [ { "billing_class": "facility", "maximum": 38216.0, "minimum": 13987.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13987.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38216.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65771", "type": "HCPCS" } ], "description": "Radial keratotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 15689.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65772", "type": "HCPCS" } ], "description": "Correction of astigmatism", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65775", "type": "HCPCS" } ], "description": "Correction of astigmatism", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65778", "type": "HCPCS" } ], "description": "Cover eye w/membrane", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65779", "type": "HCPCS" } ], "description": "Cover eye w/membrane suture", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65780", "type": "HCPCS" } ], "description": "Ocular reconst transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65781", "type": "HCPCS" } ], "description": "Ocular reconst transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65782", "type": "HCPCS" } ], "description": "Ocular reconst transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65785", "type": "HCPCS" } ], "description": "Impltj ntrstrml crnl rng seg", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65800", "type": "HCPCS" } ], "description": "Drainage of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { 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"outpatient" } ] }, { "code_information": [ { "code": "65850", "type": "HCPCS" } ], "description": "Incision of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65855", "type": "HCPCS" } ], "description": "Trabeculoplasty laser surg", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65860", "type": "HCPCS" } ], "description": "Incise inner eye adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65865", "type": "HCPCS" } ], "description": "Incise inner eye adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65870", "type": "HCPCS" } ], "description": "Incise inner eye adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65875", "type": "HCPCS" } ], "description": "Incise inner eye adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65880", "type": "HCPCS" } ], "description": "Incise inner eye adhesions", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65900", "type": "HCPCS" } ], "description": "Remove eye lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65920", "type": "HCPCS" } ], "description": "Remove implant of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "65930", "type": "HCPCS" } ], "description": "Remove blood clot from eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66020", "type": "HCPCS" } ], "description": "Injection treatment of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66030", "type": "HCPCS" } ], "description": "Injection treatment of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66130", "type": "HCPCS" } ], "description": "Remove eye lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66150", "type": "HCPCS" } ], "description": "Glaucoma surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66155", "type": "HCPCS" } ], "description": "Glaucoma surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66160", "type": "HCPCS" } ], "description": "Glaucoma surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66170", "type": "HCPCS" } ], "description": "Glaucoma surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66172", "type": "HCPCS" } ], "description": "Incision of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66174", "type": "HCPCS" } ], "description": "Translum dil eye canal", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66175", "type": "HCPCS" } ], "description": "Trnslum dil eye canal w/stnt", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66179", "type": "HCPCS" } ], "description": "Aqueous shunt eye w/o graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66180", "type": "HCPCS" } ], "description": "Aqueous shunt eye w/graft", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66183", "type": "HCPCS" } ], "description": "Insert ant drainage device", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66184", "type": "HCPCS" } ], "description": "Revision of aqueous shunt", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66185", "type": "HCPCS" } ], "description": "Revise aqueous shunt eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66225", "type": "HCPCS" } ], "description": "Repair/graft eye lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66250", "type": "HCPCS" } ], "description": "Follow-up surgery of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66500", "type": "HCPCS" } ], "description": "Incision of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66505", "type": "HCPCS" } ], "description": "Incision of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66600", "type": "HCPCS" } ], "description": "Remove iris and lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66605", "type": "HCPCS" } ], "description": "Removal of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66625", "type": "HCPCS" } ], "description": "Removal of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66630", "type": "HCPCS" } ], "description": "Removal of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66635", "type": "HCPCS" } ], "description": "Removal of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66680", "type": "HCPCS" } ], "description": "Repair iris & ciliary body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66682", "type": "HCPCS" } ], "description": "Repair iris & ciliary body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66700", "type": "HCPCS" } ], "description": "Destruction ciliary body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66710", "type": "HCPCS" } ], "description": "Ciliary transsleral therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66711", "type": "HCPCS" } ], "description": "Ciliary endoscopic ablation", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66720", "type": "HCPCS" } ], "description": "Destruction ciliary body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66740", "type": "HCPCS" } ], "description": "Destruction ciliary body", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66761", "type": "HCPCS" } ], "description": "Revision of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66762", "type": "HCPCS" } ], "description": "Revision of iris", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66770", "type": "HCPCS" } ], "description": "Removal of inner eye lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66820", "type": "HCPCS" } ], "description": "Incision secondary cataract", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66821", "type": "HCPCS" } ], "description": "After cataract laser surgery", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66825", "type": "HCPCS" } ], "description": "Reposition intraocular lens", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66830", "type": "HCPCS" } ], "description": "Removal of lens lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66840", "type": "HCPCS" } ], "description": "Removal of lens material", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66850", "type": "HCPCS" } ], "description": "Removal of lens material", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66852", "type": "HCPCS" } ], "description": "Removal of lens material", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66920", "type": "HCPCS" } ], "description": "Extraction of lens", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66930", "type": "HCPCS" } ], "description": "Extraction of lens", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66940", "type": "HCPCS" } ], "description": "Extraction of lens", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66982", "type": "HCPCS" } ], "description": "Cataract surgery complex", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66983", "type": "HCPCS" } ], "description": "Cataract surg w/iol 1 stage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66984", "type": "HCPCS" } ], "description": "Cataract surg w/iol 1 stage", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66985", "type": "HCPCS" } ], "description": "Insert lens prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66986", "type": "HCPCS" } ], "description": "Exchange lens prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66987", "type": "HCPCS" } ], "description": "Xcapsl ctrc rmvl cplx w/ecp", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66988", "type": "HCPCS" } ], "description": "Xcapsl ctrc rmvl w/ecp", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66989", "type": "HCPCS" } ], "description": "Xcpsl ctrc rmvl cplx insj 1+", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66991", "type": "HCPCS" } ], "description": "Xcapsl ctrc rmvl insj 1+", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "66999", "type": "HCPCS" } ], "description": "Eye surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67005", "type": "HCPCS" } ], "description": "Partial removal of eye fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67010", "type": "HCPCS" } ], "description": "Partial removal of eye fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67015", "type": "HCPCS" } ], "description": "Release of eye fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67025", "type": "HCPCS" } ], "description": "Replace eye fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67027", "type": "HCPCS" } ], "description": "Implant eye drug system", "standard_charges": [ { "billing_class": "facility", "maximum": 63079.0, "minimum": 13453.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13453.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63079.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67028", "type": "HCPCS" } ], "description": "Injection eye drug", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 318.49, "payers_information": [ { 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"outpatient" } ] }, { "code_information": [ { "code": "67039", "type": "HCPCS" } ], "description": "Laser treatment of retina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67040", "type": "HCPCS" } ], "description": "Laser treatment of retina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67041", "type": "HCPCS" } ], "description": "Vit for macular pucker", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67042", "type": "HCPCS" } ], "description": "Vit for macular hole", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67043", "type": "HCPCS" } ], "description": "Vit for membrane dissect", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67101", "type": "HCPCS" } ], "description": "Repair detached retina crtx", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67105", "type": "HCPCS" } ], "description": "Repair detached retina pc", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67107", "type": "HCPCS" } ], "description": "Repair detached retina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67108", "type": "HCPCS" } ], "description": "Repair detached retina", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67110", "type": "HCPCS" } ], "description": "Repair detached retina", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67113", "type": "HCPCS" } ], "description": "Repair retinal detach cplx", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 5130.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5130.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67115", "type": "HCPCS" } ], "description": "Release encircling material", "standard_charges": [ { "billing_class": "facility", "maximum": 20001.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20001.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67120", "type": "HCPCS" } ], "description": "Remove eye implant material", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67121", "type": "HCPCS" } ], "description": "Remove eye implant material", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67141", "type": "HCPCS" } ], "description": "Treatment of retina", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67145", "type": "HCPCS" } ], "description": "Treatment of retina", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67208", "type": "HCPCS" } ], "description": "Treatment of retinal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67210", "type": "HCPCS" } ], "description": "Treatment of retinal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67218", "type": "HCPCS" } ], "description": "Treatment of retinal lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67220", "type": "HCPCS" } ], "description": "Treatment of choroid lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67221", "type": "HCPCS" } ], "description": "Ocular Photodynamic Ther", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67227", "type": "HCPCS" } ], "description": "Dstrj extensive retinopathy", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67228", "type": "HCPCS" } ], "description": "Treatment x10sv retinopathy", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67229", "type": "HCPCS" } ], "description": "Tr retinal les preterm inf", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 530.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 530.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67250", "type": "HCPCS" } ], "description": "Reinforce eye wall", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67255", "type": "HCPCS" } ], "description": "Reinforce/graft eye wall", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 3985.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3985.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67299", "type": "HCPCS" } ], "description": "Eye surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 2225.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2225.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67311", "type": "HCPCS" } ], "description": "Revise eye muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67312", "type": "HCPCS" } ], "description": "Revise two eye muscles", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67314", "type": "HCPCS" } ], "description": "Revise eye muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67316", "type": "HCPCS" } ], "description": "Revise two eye muscles", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67318", "type": "HCPCS" } ], "description": "Revise eye muscle(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67343", "type": "HCPCS" } ], "description": "Release eye tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67345", "type": "HCPCS" } ], "description": "Destroy nerve of eye muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67346", "type": "HCPCS" } ], "description": "Biopsy eye muscle", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67399", "type": "HCPCS" } ], "description": "Unlisted px extraocular musc", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67400", "type": "HCPCS" } ], "description": "Explore/biopsy eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67405", "type": "HCPCS" } ], "description": "Explore/drain eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67412", "type": "HCPCS" } ], "description": "Explore/treat eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67413", "type": "HCPCS" } ], "description": "Explore/treat eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67414", "type": "HCPCS" } ], "description": "Explr/decompress eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67415", "type": "HCPCS" } ], "description": "Aspiration orbital contents", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67420", "type": "HCPCS" } ], "description": "Explore/treat eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67430", "type": "HCPCS" } ], "description": "Explore/treat eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67440", "type": "HCPCS" } ], "description": "Explore/drain eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67445", "type": "HCPCS" } ], "description": "Explr/decompress eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67450", "type": "HCPCS" } ], "description": "Explore/biopsy eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67500", "type": "HCPCS" } ], "description": "Inject/treat eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67505", "type": "HCPCS" } ], "description": "Inject/treat eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67515", "type": "HCPCS" } ], "description": "Inject/treat eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67550", "type": "HCPCS" } ], "description": "Insert eye socket implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67560", "type": "HCPCS" } ], "description": "Revise eye socket implant", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67570", "type": "HCPCS" } ], "description": "Decompress optic nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67599", "type": "HCPCS" } ], "description": "Orbit surgery procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 16564.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16564.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67700", "type": "HCPCS" } ], "description": "Drainage of eyelid abscess", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67710", "type": "HCPCS" } ], "description": "Incision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67715", "type": "HCPCS" } ], "description": "Incision of eyelid fold", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67800", "type": "HCPCS" } ], "description": "Remove eyelid lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67801", "type": "HCPCS" } ], "description": "Remove eyelid lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67805", "type": "HCPCS" } ], "description": "Remove eyelid lesions", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67808", "type": "HCPCS" } ], "description": "Remove eyelid lesion(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67810", "type": "HCPCS" } ], "description": "Biopsy eyelid & lid margin", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67820", "type": "HCPCS" } ], "description": "Revise eyelashes", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67825", "type": "HCPCS" } ], "description": "Revise eyelashes", "standard_charges": [ { "billing_class": "facility", "maximum": 3714.0, "minimum": 306.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 306.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3714.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67830", "type": "HCPCS" } ], "description": "Revise eyelashes", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67835", "type": "HCPCS" } ], "description": "Revise eyelashes", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67840", "type": "HCPCS" } ], "description": "Remove eyelid lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67850", "type": "HCPCS" } ], "description": "Treat eyelid lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67875", "type": "HCPCS" } ], "description": "Closure of eyelid by suture", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 961.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 961.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67880", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67882", "type": "HCPCS" } ], "description": "Revision of eyelid", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67900", "type": "HCPCS" } ], "description": "Repair brow defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67901", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67902", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67903", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67904", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67906", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 15689.0, "minimum": 3790.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15689.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67908", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67909", "type": "HCPCS" } ], "description": "Revise eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67911", "type": "HCPCS" } ], "description": "Revise eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67912", "type": "HCPCS" } ], "description": "Correction eyelid w/implant", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "67914", "type": "HCPCS" } ], "description": "Repair eyelid defect", "standard_charges": [ { "billing_class": "facility", "maximum": 9206.0, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 9206.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "001", "type": "MS-DRG" } ], "description": "Heart Transplant Or Implant Of Heart Assist System With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 623350.6, "minimum": 218838.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 623350.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 557187.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 581664.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 524035.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 491616.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 218838.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 520712.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 213219.4, "90th_percentile": 213219.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 213219.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 521816.09, "90th_percentile": 521816.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 521816.09, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 999772.0, "90th_percentile": 1526491.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1323211.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 211830.19, "90th_percentile": 211830.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 211830.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 343634.33, "90th_percentile": 343634.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 343634.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 309174.14, "90th_percentile": 309174.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 309174.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 937145.28, "90th_percentile": 937145.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 937145.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 234216.32, "90th_percentile": 234216.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 234216.32, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1449668.48, "90th_percentile": 1449668.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1449668.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 349749.51, "90th_percentile": 349749.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 349749.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 202792.32, "90th_percentile": 202792.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 202792.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "002", "type": "MS-DRG" } ], "description": "Heart Transplant Or Implant Of Heart Assist System Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 243876.98, "minimum": 89211.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 243876.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 217991.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 227567.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 205021.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 192337.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89211.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 203721.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "003", "type": "MS-DRG" } ], "description": "Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major", "standard_charges": [ { "billing_class": "facility", "maximum": 474271.76, "minimum": 166041.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 474271.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 423932.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 442555.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 398708.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 374042.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166041.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 396180.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 369555.83, "90th_percentile": 515255.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 403556.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 145074.03, "90th_percentile": 172240.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 160759.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 131076.84, "90th_percentile": 131076.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 131076.84, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 110259.55, "90th_percentile": 110259.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110259.55, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 418370.75, "90th_percentile": 1528084.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 673554.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 113476.65, "90th_percentile": 248877.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 162469.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 170116.92, "90th_percentile": 254455.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 248385.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 73346.68, "90th_percentile": 105899.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73346.68, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 142602.82, "90th_percentile": 142602.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 142602.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 50189.17, "90th_percentile": 361256.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85161.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 522453.76, "90th_percentile": 522453.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 522453.76, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 148200.08, "90th_percentile": 148200.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 148200.08, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 99290.83, "90th_percentile": 163036.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 145725.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 323698.36, "90th_percentile": 563258.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 337036.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 160940.19, "90th_percentile": 160940.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 160940.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 231052.71, "90th_percentile": 231052.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 231052.71, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 168402.48, "90th_percentile": 168402.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 168402.48, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 322551.45, "90th_percentile": 1505210.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 322551.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 156236.25, "90th_percentile": 156236.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 156236.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 93572.38, "90th_percentile": 217361.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 156442.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 458407.0, "90th_percentile": 1171233.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 559211.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "004", "type": "MS-DRG" } ], "description": "Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.", "standard_charges": [ { "billing_class": "facility", "maximum": 312691.11, "minimum": 108777.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 312691.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 279501.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 291780.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 262871.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 246609.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108777.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 261204.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 198721.01, "90th_percentile": 198721.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 198721.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 103652.05, "90th_percentile": 107443.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 107394.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 697789.0, "90th_percentile": 697789.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 697789.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 65425.72, "90th_percentile": 107758.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 102571.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 56749.01, "90th_percentile": 56749.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56749.01, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8228.35, "90th_percentile": 127186.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46654.56, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 69119.96, "90th_percentile": 69119.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69119.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 100230.07, "90th_percentile": 235996.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 105727.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 64229.41, "90th_percentile": 64229.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64229.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 537014.99, "90th_percentile": 537014.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 537014.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 98331.4, "90th_percentile": 130894.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 106385.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 412381.98, "90th_percentile": 412381.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 412381.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "005", "type": "MS-DRG" } ], "description": "Liver Transplant With Mcc Or Intestinal Transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 235664.17, "minimum": 81280.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 235664.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 210650.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 219904.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 198117.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 185860.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81280.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 196860.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "006", "type": "MS-DRG" } ], "description": "Liver Transplant Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 107311.01, "minimum": 37220.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 107311.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 95920.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 100134.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90213.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84632.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37220.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 89641.61 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "007", "type": "MS-DRG" } ], "description": "Lung Transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 289205.69, "minimum": 101779.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 289205.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 258509.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 269865.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 243128.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 228087.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101779.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 241586.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "008", "type": "MS-DRG" } ], "description": "Simultaneous Pancreas And Kidney Transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 120410.34, "minimum": 44734.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 120410.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 107629.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 112357.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101226.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94963.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44734.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100584.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "010", "type": "MS-DRG" } ], "description": "Pancreas Transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 176441.61, "minimum": 56935.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 176441.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 157713.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 164642.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 148330.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 139153.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56935.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 147389.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "011", "type": "MS-DRG" } ], "description": "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 119410.02, "minimum": 43566.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 119410.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 106735.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 111424.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100385.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94174.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43566.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99748.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42325.01, "90th_percentile": 42325.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42325.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10260.94, "90th_percentile": 10260.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10260.94, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "012", "type": "MS-DRG" } ], "description": "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 90812.35, "minimum": 33951.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90812.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 81173.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 84739.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76343.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71620.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33951.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75859.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "013", "type": "MS-DRG" } ], "description": "Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 58642.72, "minimum": 23590.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58642.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52418.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 54721.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49299.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46249.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23590.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48986.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "014", "type": "MS-DRG" } ], "description": "Allogeneic Bone Marrow Transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 289936.02, "minimum": 94539.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 289936.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 259162.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 270546.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 243742.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 228663.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94539.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 242196.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 215000.0, "90th_percentile": 215000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 215000.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 296947.55, "90th_percentile": 376488.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 296947.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 187600.95, "90th_percentile": 187600.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 187600.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9286.94, "90th_percentile": 9286.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9286.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "016", "type": "MS-DRG" } ], "description": "Autologous Bone Marrow Transplant With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 133571.65, "minimum": 47259.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 133571.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 119394.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 124639.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112290.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 105343.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47259.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111578.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 140000.0, "90th_percentile": 182358.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 140000.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46418.74, "90th_percentile": 46418.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46418.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 61507.7, "90th_percentile": 61507.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61507.7, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 119402.17, "90th_percentile": 864683.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 125860.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46380.05, "90th_percentile": 46380.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46380.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 63755.09, "90th_percentile": 63755.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63755.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 34161.44, "90th_percentile": 34161.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34161.44, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42982.27, "90th_percentile": 156172.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42982.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4278.43, "90th_percentile": 4278.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4278.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 72000.0, "90th_percentile": 72000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72000.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "017", "type": "MS-DRG" } ], "description": "Autologous Bone Marrow Transplant Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 133571.65, "minimum": 43396.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 133571.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 119394.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 124639.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112290.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 105343.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43396.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 111578.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "018", "type": "MS-DRG" } ], "description": "Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies", "standard_charges": [ { "billing_class": "facility", "maximum": 834564.44, "minimum": 336560.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 834564.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 745983.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 778753.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 701598.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 658193.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336560.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 697148.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "019", "type": "MS-DRG" } ], "description": "Simultaneous Pancreas And Kidney Transplant With Hemodialysis", "standard_charges": [ { "billing_class": "facility", "maximum": 175425.8, "minimum": 56616.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 175425.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 156805.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 163694.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147476.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 138352.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56616.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 146540.9 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "020", "type": "MS-DRG" } ], "description": "Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 178386.93, "minimum": 62318.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 178386.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 159452.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 166457.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 149965.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 140687.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62318.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 149014.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 276840.61, "90th_percentile": 276840.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 276840.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60504.81, "90th_percentile": 61698.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60504.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42084.03, "90th_percentile": 42084.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42084.03, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 238852.2, "90th_percentile": 404315.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 311209.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 100588.23, "90th_percentile": 100588.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 100588.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 94426.68, "90th_percentile": 94426.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 94426.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 82863.78, "90th_percentile": 82863.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82863.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60055.41, "90th_percentile": 61681.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60055.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 304895.32, "90th_percentile": 304895.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 304895.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 59846.85, "90th_percentile": 59846.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59846.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32307.16, "90th_percentile": 32307.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32307.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 140415.7, "90th_percentile": 140415.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 140415.7, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 59059.27, "90th_percentile": 61098.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60200.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 289270.91, "90th_percentile": 289270.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 289270.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "021", "type": "MS-DRG" } ], "description": "Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 122324.68, "minimum": 42321.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 122324.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 109341.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 114144.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102835.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 96473.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42321.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102183.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3787.14, "90th_percentile": 3787.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3787.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 286731.5, "90th_percentile": 343689.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 297819.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 38175.38, "90th_percentile": 38175.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38175.38, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42608.69, "90th_percentile": 42608.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42608.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39021.67, "90th_percentile": 39021.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39021.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 188872.09, "90th_percentile": 188872.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 188872.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 265436.03, "90th_percentile": 265436.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 265436.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "022", "type": "MS-DRG" } ], "description": "Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 78131.28, "minimum": 25885.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78131.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69838.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 72906.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65683.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61619.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25885.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65266.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27505.66, "90th_percentile": 27505.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27505.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 253679.8, "90th_percentile": 253679.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 253679.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25378.88, "90th_percentile": 25378.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25378.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "023", "type": "MS-DRG" } ], "description": "Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla", "standard_charges": [ { "billing_class": "facility", "maximum": 126250.72, "minimum": 45711.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 126250.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 112850.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 117807.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106135.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99569.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45711.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 105462.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 119806.28, "90th_percentile": 297301.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 144481.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38442.5, "90th_percentile": 43939.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 42436.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 142279.04, "90th_percentile": 142279.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 142279.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 60672.84, "90th_percentile": 60672.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60672.84, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16835.3, "90th_percentile": 16835.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16835.3, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 112059.57, "90th_percentile": 313842.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 209816.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 99136.1, "90th_percentile": 99136.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99136.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31612.57, "90th_percentile": 44036.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 41920.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 76385.72, "90th_percentile": 287806.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76385.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 23436.32, "90th_percentile": 23436.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23436.32, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 36650.32, "90th_percentile": 45955.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38093.31, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 313328.81, "90th_percentile": 313328.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 313328.81, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 43645.36, "90th_percentile": 43645.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43645.36, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39892.89, "90th_percentile": 44058.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 42267.59, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 199774.86, "90th_percentile": 280602.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 224390.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 10606.28, "90th_percentile": 10606.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10606.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 43976.83, "90th_percentile": 43976.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43976.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 42622.66, "90th_percentile": 49888.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43161.47, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24055.34, "90th_percentile": 42084.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28526.31, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 38841.92, "90th_percentile": 38841.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38841.92, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 106753.71, "90th_percentile": 106753.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 106753.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 48143.66, "90th_percentile": 48143.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48143.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38423.79, "90th_percentile": 44652.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 43129.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 99576.82, "90th_percentile": 306614.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 290070.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "024", "type": "MS-DRG" } ], "description": "Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 84128.78, "minimum": 31589.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84128.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 75199.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 78502.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70725.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66349.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31589.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70276.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 91263.22, "90th_percentile": 91263.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 91263.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29567.11, "90th_percentile": 30712.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29656.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74672.99, "90th_percentile": 215499.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76900.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28807.08, "90th_percentile": 29328.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28807.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 25821.23, "90th_percentile": 25821.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25821.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 112298.36, "90th_percentile": 112298.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 112298.36, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27278.43, "90th_percentile": 29787.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27956.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 77430.46, "90th_percentile": 77430.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77430.46, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 30003.33, "90th_percentile": 30003.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30003.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 29545.47, "90th_percentile": 29545.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29545.47, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29112.34, "90th_percentile": 29112.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29112.34, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 69577.32, "90th_percentile": 69577.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69577.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 27136.79, "90th_percentile": 27136.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27136.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28330.92, "90th_percentile": 28330.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28330.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 65620.67, "90th_percentile": 65620.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65620.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "025", "type": "MS-DRG" } ], "description": "Craniotomy And Endovascular Intracranial Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 98969.83, "minimum": 36519.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 98969.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 88465.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 92351.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83201.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78054.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36519.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82673.86 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 98882.55, "90th_percentile": 192778.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 128425.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21699.83, "90th_percentile": 35500.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 33676.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 295591.08, "90th_percentile": 295591.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 295591.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 34512.71, "90th_percentile": 34512.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34512.71, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 64614.32, "90th_percentile": 64614.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64614.32, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 87844.92, "90th_percentile": 402345.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 90667.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 23159.11, "90th_percentile": 23159.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23159.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31416.67, "90th_percentile": 36800.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 34621.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 103263.92, "90th_percentile": 194960.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 103263.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 16918.75, "90th_percentile": 27851.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21590.01, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14526.54, "90th_percentile": 45955.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 18699.67, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31737.79, "90th_percentile": 31737.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31737.79, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 226145.41, "90th_percentile": 226145.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 226145.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 149364.31, "90th_percentile": 237312.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 158636.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 22038.93, "90th_percentile": 34161.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32883.78, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32805.75, "90th_percentile": 42448.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 33844.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 218501.29, "90th_percentile": 218501.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 218501.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 78602.49, "90th_percentile": 78602.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78602.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 34608.97, "90th_percentile": 67361.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34628.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 32388.73, "90th_percentile": 34862.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32388.73, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21098.78, "90th_percentile": 50860.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42953.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35125.34, "90th_percentile": 35125.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35125.34, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 187040.13, "90th_percentile": 187040.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 187040.13, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 80048.33, "90th_percentile": 252470.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 84807.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 50539.1, "90th_percentile": 50539.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50539.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25441.49, "90th_percentile": 36412.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 34580.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 83182.69, "90th_percentile": 222940.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 87109.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "026", "type": "MS-DRG" } ], "description": "Craniotomy And Endovascular Intracranial Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 67685.45, "minimum": 25356.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67685.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 60501.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 63159.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56901.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53381.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25356.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56540.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 65547.61, "90th_percentile": 262499.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 81449.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21786.62, "90th_percentile": 24023.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 23417.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21098.78, "90th_percentile": 21098.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21098.78, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 57709.05, "90th_percentile": 561709.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63777.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 15443.39, "90th_percentile": 20189.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19768.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22304.85, "90th_percentile": 24859.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23990.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 36718.21, "90th_percentile": 36718.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36718.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 17279.17, "90th_percentile": 20371.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17279.17, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 18699.67, "90th_percentile": 19098.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19098.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 103826.37, "90th_percentile": 109450.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 103826.37, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 24391.99, "90th_percentile": 24665.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24391.99, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 21098.78, "90th_percentile": 21098.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21098.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21806.03, "90th_percentile": 31084.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23540.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 60006.67, "90th_percentile": 222726.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66759.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 121915.23, "90th_percentile": 121915.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121915.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 79605.6, "90th_percentile": 79605.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79605.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21098.78, "90th_percentile": 21189.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21098.78, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 204034.69, "90th_percentile": 292725.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 204034.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 20007.46, "90th_percentile": 20007.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20007.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22395.46, "90th_percentile": 25091.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23822.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 55617.73, "90th_percentile": 285608.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63424.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "027", "type": "MS-DRG" } ], "description": "Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 54610.46, "minimum": 20802.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54610.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48814.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 50958.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45909.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43069.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20802.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45618.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 53786.06, "90th_percentile": 228627.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85992.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17757.16, "90th_percentile": 20087.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 19491.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21098.78, "90th_percentile": 21098.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21098.78, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48472.53, "90th_percentile": 48818.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 48472.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 20276.1, "90th_percentile": 23245.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20276.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17840.71, "90th_percentile": 19905.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17849.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 17279.17, "90th_percentile": 17279.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17279.17, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13017.41, "90th_percentile": 19098.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 16855.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 89947.02, "90th_percentile": 165271.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 89947.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 108128.35, "90th_percentile": 125300.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108128.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 19854.02, "90th_percentile": 19854.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19854.02, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 21098.78, "90th_percentile": 21098.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21098.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18838.62, "90th_percentile": 20218.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19491.75, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 73357.52, "90th_percentile": 73357.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73357.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 1749.25, "90th_percentile": 1749.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1749.25, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13248.33, "90th_percentile": 21098.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13248.33, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 51282.74, "90th_percentile": 71297.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66665.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 20007.46, "90th_percentile": 20007.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20007.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17906.45, "90th_percentile": 20226.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 19660.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 75287.72, "90th_percentile": 227942.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78266.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "028", "type": "MS-DRG" } ], "description": "Spinal Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 134536.56, "minimum": 47869.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 134536.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 120256.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 125539.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113101.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106104.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47869.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112384.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42786.7, "90th_percentile": 45119.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44881.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 355642.95, "90th_percentile": 355642.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 355642.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46729.85, "90th_percentile": 46736.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46729.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 84615.62, "90th_percentile": 84615.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84615.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 24496.24, "90th_percentile": 24496.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24496.24, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 45625.5, "90th_percentile": 45625.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45625.5, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44647.35, "90th_percentile": 44647.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44647.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 113109.1, "90th_percentile": 113109.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 113109.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 75703.88, "90th_percentile": 75703.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75703.88, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30001.87, "90th_percentile": 30001.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30001.87, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 141331.97, "90th_percentile": 141331.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 141331.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46088.73, "90th_percentile": 46088.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46088.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "029", "type": "MS-DRG" } ], "description": "Spinal Procedures With Cc Or Spinal Neurostimulators", "standard_charges": [ { "billing_class": "facility", "maximum": 74282.7, "minimum": 27704.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74282.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 66398.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 69315.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62447.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58584.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27704.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62051.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 65932.3, "90th_percentile": 71138.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65932.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 18473.09, "90th_percentile": 18473.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18473.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 24931.73, "90th_percentile": 24931.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24931.73, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24042.54, "90th_percentile": 26195.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24907.81, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 66849.25, "90th_percentile": 66849.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66849.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 23838.53, "90th_percentile": 23838.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23838.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13220.51, "90th_percentile": 13220.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13220.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 55766.44, "90th_percentile": 55766.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55766.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 20527.32, "90th_percentile": 20527.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20527.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25240.79, "90th_percentile": 26456.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25375.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 59548.07, "90th_percentile": 158238.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62209.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "030", "type": "MS-DRG" } ], "description": "Spinal Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 49245.9, "minimum": 18258.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49245.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44018.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 45952.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41399.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38838.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18258.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41137.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17663.84, "90th_percentile": 17663.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17663.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43711.31, "90th_percentile": 43711.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43711.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15825.72, "90th_percentile": 15825.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15825.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15499.92, "90th_percentile": 15499.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15499.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40519.0, "90th_percentile": 40519.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40519.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "031", "type": "MS-DRG" } ], "description": "Ventricular Shunt Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 92735.53, "minimum": 36005.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92735.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 82892.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 86533.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77960.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73137.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36005.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77466.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30411.94, "90th_percentile": 30411.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30411.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 344759.56, "90th_percentile": 344759.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 344759.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21519.23, "90th_percentile": 21519.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21519.23, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 72799.18, "90th_percentile": 72799.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72799.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "032", "type": "MS-DRG" } ], "description": "Ventricular Shunt Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 47260.75, "minimum": 17759.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47260.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42244.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44100.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39730.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37273.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17759.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39478.99 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 47262.96, "90th_percentile": 47262.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47262.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15964.71, "90th_percentile": 17001.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16993.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44491.5, "90th_percentile": 44491.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44491.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 11735.55, "90th_percentile": 11735.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11735.55, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 17573.63, "90th_percentile": 17573.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17573.63, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 57908.89, "90th_percentile": 57908.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57908.89, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 1524.5, "90th_percentile": 1524.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1524.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17723.17, "90th_percentile": 17723.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17723.17, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37274.76, "90th_percentile": 37274.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37274.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16156.18, "90th_percentile": 17257.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17189.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37274.76, "90th_percentile": 37274.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37274.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "033", "type": "MS-DRG" } ], "description": "Ventricular Shunt Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35307.8, "minimum": 14124.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35307.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31560.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32946.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29682.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27846.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14124.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29494.16 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11782.11, "90th_percentile": 11782.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11782.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31338.81, "90th_percentile": 31338.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31338.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11820.3, "90th_percentile": 11820.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11820.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13148.16, "90th_percentile": 13148.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13148.16, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12905.17, "90th_percentile": 12905.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12905.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "034", "type": "MS-DRG" } ], "description": "Carotid Artery Stent Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 86056.39, "minimum": 31269.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86056.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 76922.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 80301.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72345.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67869.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31269.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71886.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28545.82, "90th_percentile": 28545.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28545.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28067.76, "90th_percentile": 28067.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28067.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 28623.13, "90th_percentile": 28623.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28623.13, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29423.65, "90th_percentile": 29423.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29423.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28806.72, "90th_percentile": 28806.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28806.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "035", "type": "MS-DRG" } ], "description": "Carotid Artery Stent Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 50339.17, "minimum": 19774.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50339.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44996.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46972.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42318.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39700.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19774.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42050.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18028.48, "90th_percentile": 19224.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18044.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44681.62, "90th_percentile": 46820.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44781.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17649.14, "90th_percentile": 18041.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17732.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 22799.57, "90th_percentile": 22799.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22799.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 17978.91, "90th_percentile": 17978.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17978.91, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16855.23, "90th_percentile": 16855.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16855.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 109465.39, "90th_percentile": 109465.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 109465.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15855.07, "90th_percentile": 15855.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15855.07, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15894.91, "90th_percentile": 18036.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17123.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17667.96, "90th_percentile": 17667.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17667.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18067.95, "90th_percentile": 18067.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18067.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "036", "type": "MS-DRG" } ], "description": "Carotid Artery Stent Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40566.12, "minimum": 16298.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40566.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36260.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37853.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34102.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31993.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16298.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33886.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 58730.11, "90th_percentile": 58730.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58730.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13402.51, "90th_percentile": 15840.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14423.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36005.75, "90th_percentile": 40025.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36005.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14401.26, "90th_percentile": 14401.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14401.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 23564.31, "90th_percentile": 32103.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23564.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37584.13, "90th_percentile": 37584.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37584.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 18621.02, "90th_percentile": 18621.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18621.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13316.65, "90th_percentile": 15527.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14704.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40411.13, "90th_percentile": 40411.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40411.13, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18621.02, "90th_percentile": 18621.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18621.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40750.17, "90th_percentile": 40750.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40750.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14739.07, "90th_percentile": 15570.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14808.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38937.91, "90th_percentile": 38937.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38937.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "037", "type": "MS-DRG" } ], "description": "Extracranial Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 73490.41, "minimum": 26776.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73490.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 65690.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 68575.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61781.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57959.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26776.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61389.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23587.63, "90th_percentile": 23587.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23587.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25980.82, "90th_percentile": 25980.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25980.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14468.04, "90th_percentile": 14468.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14468.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20834.63, "90th_percentile": 20834.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20834.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24538.52, "90th_percentile": 26294.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25023.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 25946.61, "90th_percentile": 25946.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25946.61, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25074.48, "90th_percentile": 25074.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25074.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "038", "type": "MS-DRG" } ], "description": "Extracranial Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 35655.25, "minimum": 13811.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35655.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31870.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33270.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29974.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28120.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13811.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29784.41 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 35234.79, "90th_percentile": 35234.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35234.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13071.02, "90th_percentile": 13071.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13071.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 12136.07, "90th_percentile": 12136.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12136.07, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31649.15, "90th_percentile": 31649.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31649.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13069.06, "90th_percentile": 13076.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13069.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 19098.03, "90th_percentile": 19098.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19098.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 72077.69, "90th_percentile": 90659.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72077.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13050.74, "90th_percentile": 13158.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13050.74, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32094.83, "90th_percentile": 32094.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32094.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13090.26, "90th_percentile": 13423.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13090.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11391.41, "90th_percentile": 13160.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11975.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30232.96, "90th_percentile": 30232.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30232.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "039", "type": "MS-DRG" } ], "description": "Extracranial Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25189.5, "minimum": 10339.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25189.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22515.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23504.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21176.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19866.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10339.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21041.9 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8659.13, "90th_percentile": 9534.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 9465.91, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22356.52, "90th_percentile": 24217.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22356.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8494.01, "90th_percentile": 10136.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9466.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 22544.36, "90th_percentile": 22544.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22544.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13362.35, "90th_percentile": 13362.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13362.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 26039.6, "90th_percentile": 26039.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26039.6, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9464.37, "90th_percentile": 10052.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9470.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22790.02, "90th_percentile": 22790.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22790.02, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 42541.06, "90th_percentile": 42541.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42541.06, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9206.95, "90th_percentile": 9206.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9206.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21098.78, "90th_percentile": 21098.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21098.78, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9555.98, "90th_percentile": 9555.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9555.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "040", "type": "MS-DRG" } ], "description": "Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 83473.71, "minimum": 31195.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83473.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 74613.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 77891.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70174.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65833.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31195.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69729.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 90705.89, "90th_percentile": 90705.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90705.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23002.39, "90th_percentile": 29419.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26667.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 62808.3, "90th_percentile": 79548.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74769.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 18150.28, "90th_percentile": 18150.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18150.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21589.46, "90th_percentile": 29432.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27182.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 145908.67, "90th_percentile": 145908.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 145908.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 88335.55, "90th_percentile": 88335.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 88335.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 28743.91, "90th_percentile": 28743.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28743.91, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25059.47, "90th_percentile": 29358.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27630.82, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 82175.01, "90th_percentile": 82175.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82175.01, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 27717.12, "90th_percentile": 27717.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27717.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10938.94, "90th_percentile": 10938.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10938.94, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2762.27, "90th_percentile": 2762.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2762.27, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 295667.96, "90th_percentile": 295667.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 295667.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29221.08, "90th_percentile": 32862.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29221.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "041", "type": "MS-DRG" } ], "description": "Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator", "standard_charges": [ { "billing_class": "facility", "maximum": 49985.08, "minimum": 18285.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49985.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44679.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46642.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42021.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39421.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18285.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41754.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 76842.8, "90th_percentile": 76842.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76842.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16147.94, "90th_percentile": 17949.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 16409.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42049.0, "90th_percentile": 44355.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44355.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16782.32, "90th_percentile": 17995.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17951.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 11525.89, "90th_percentile": 11525.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11525.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 49081.98, "90th_percentile": 49081.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49081.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16602.0, "90th_percentile": 24106.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17788.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37046.05, "90th_percentile": 37046.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37046.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11736.95, "90th_percentile": 11736.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11736.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1861.84, "90th_percentile": 18066.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17192.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "042", "type": "MS-DRG" } ], "description": "Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38895.23, "minimum": 14627.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38895.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34766.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36294.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32698.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30675.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14627.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32490.9 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 47932.54, "90th_percentile": 47932.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47932.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12576.53, "90th_percentile": 12576.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12576.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34522.78, "90th_percentile": 34522.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34522.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13223.65, "90th_percentile": 13223.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13223.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14181.66, "90th_percentile": 14181.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14181.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41621.1, "90th_percentile": 41621.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41621.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25078.3, "90th_percentile": 25078.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25078.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12231.07, "90th_percentile": 12231.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12231.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 53872.93, "90th_percentile": 53872.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53872.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "052", "type": "MS-DRG" } ], "description": "Spinal Disorders And Injuries With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 44536.42, "minimum": 15276.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44536.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39809.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41558.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37440.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35124.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15276.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37203.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14847.12, "90th_percentile": 14847.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14847.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37769.23, "90th_percentile": 37769.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37769.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12896.09, "90th_percentile": 12896.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12896.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 97558.39, "90th_percentile": 97558.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 97558.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14206.83, "90th_percentile": 14206.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14206.83, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14192.87, "90th_percentile": 14192.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14192.87, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15910.63, "90th_percentile": 23703.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15910.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "053", "type": "MS-DRG" } ], "description": "Spinal Disorders And Injuries Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20389.29, "minimum": 8814.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20389.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18225.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19025.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17140.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16080.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8814.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17032.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "054", "type": "MS-DRG" } ], "description": "Nervous System Neoplasms With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33176.58, "minimum": 13068.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33176.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29655.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30957.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27890.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26165.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13068.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27713.86 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 33145.1, "90th_percentile": 35700.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35050.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8844.07, "90th_percentile": 12195.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 10536.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29533.13, "90th_percentile": 29533.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29533.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 12461.51, "90th_percentile": 12461.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12461.51, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6891.56, "90th_percentile": 6891.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6891.56, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24223.68, "90th_percentile": 31457.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 29445.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6594.51, "90th_percentile": 6594.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6594.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10363.36, "90th_percentile": 12285.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 12181.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 9552.67, "90th_percentile": 26645.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9990.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3195.57, "90th_percentile": 13664.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9738.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20776.53, "90th_percentile": 20776.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20776.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 13423.5, "90th_percentile": 13423.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13423.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10806.57, "90th_percentile": 10806.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10806.57, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8579.25, "90th_percentile": 12230.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 11243.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29410.84, "90th_percentile": 38029.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29410.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 36226.62, "90th_percentile": 36226.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36226.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 12191.95, "90th_percentile": 12191.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12191.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15096.21, "90th_percentile": 15096.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15096.21, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26165.29, "90th_percentile": 27670.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26165.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9462.0, "90th_percentile": 12297.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 11219.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26165.29, "90th_percentile": 177138.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27670.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "055", "type": "MS-DRG" } ], "description": "Nervous System Neoplasms Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24142.71, "minimum": 9128.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24142.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21580.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22528.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20296.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19040.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9128.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20167.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9115.43, "90th_percentile": 9115.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9115.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17773.07, "90th_percentile": 17773.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17773.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5327.2, "90th_percentile": 5327.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5327.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7972.04, "90th_percentile": 9139.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9108.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 23712.89, "90th_percentile": 23712.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23712.89, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7296.09, "90th_percentile": 7296.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7296.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8012.32, "90th_percentile": 8012.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8012.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20137.68, "90th_percentile": 20137.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20137.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "056", "type": "MS-DRG" } ], "description": "Degenerative Nervous System Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 55416.02, "minimum": 19251.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55416.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49534.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 51710.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46586.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43704.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19251.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46291.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 58548.36, "90th_percentile": 58548.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58548.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10323.18, "90th_percentile": 19861.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 17996.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21485.25, "90th_percentile": 49185.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47860.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16635.03, "90th_percentile": 20269.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19790.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10417.42, "90th_percentile": 10417.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10417.42, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12221.64, "90th_percentile": 19799.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 17792.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17842.09, "90th_percentile": 19807.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17842.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 12515.64, "90th_percentile": 12515.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12515.64, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15557.56, "90th_percentile": 15557.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15557.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12401.03, "90th_percentile": 12401.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12401.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42879.78, "90th_percentile": 42879.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42879.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 25678.6, "90th_percentile": 25678.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25678.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15291.55, "90th_percentile": 20081.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20002.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43706.56, "90th_percentile": 43706.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43706.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "057", "type": "MS-DRG" } ], "description": "Degenerative Nervous System Disorders Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29538.25, "minimum": 11271.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29538.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26403.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27562.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24832.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23295.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11271.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24674.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29503.58, "90th_percentile": 29503.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29503.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 982.95, "90th_percentile": 10952.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 9988.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25180.75, "90th_percentile": 25180.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25180.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26210.28, "90th_percentile": 26397.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26210.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 945.87, "90th_percentile": 10958.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 9302.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 27824.91, "90th_percentile": 28111.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27824.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6169.83, "90th_percentile": 6169.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6169.83, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9820.18, "90th_percentile": 9820.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9820.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 11154.21, "90th_percentile": 11154.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11154.21, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9651.32, "90th_percentile": 10758.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10758.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8015.26, "90th_percentile": 10987.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 9134.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25418.38, "90th_percentile": 26179.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25418.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10984.67, "90th_percentile": 11866.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10984.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10229.75, "90th_percentile": 10229.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10229.75, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10758.29, "90th_percentile": 10758.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10758.29, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9701.52, "90th_percentile": 9818.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9701.52, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23290.62, "90th_percentile": 24630.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23914.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10201.83, "90th_percentile": 10201.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10201.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1065.53, "90th_percentile": 11050.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 9863.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23290.62, "90th_percentile": 23290.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23290.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "058", "type": "MS-DRG" } ], "description": "Multiple Sclerosis And Cerebellar Ataxia With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40847.19, "minimum": 14486.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40847.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36511.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38115.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34339.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32214.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14486.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34121.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 40812.84, "90th_percentile": 40812.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40812.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25816.65, "90th_percentile": 25816.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25816.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14202.26, "90th_percentile": 14202.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14202.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8705.03, "90th_percentile": 8705.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8705.03, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 36431.55, "90th_percentile": 36431.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36431.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14801.6, "90th_percentile": 14801.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14801.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36214.71, "90th_percentile": 36214.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36214.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1308.43, "90th_percentile": 1308.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1308.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "059", "type": "MS-DRG" } ], "description": "Multiple Sclerosis And Cerebellar Ataxia With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 27077.28, "minimum": 10847.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27077.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24203.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25266.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22763.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21354.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10847.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22618.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 27053.8, "90th_percentile": 28039.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27053.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10346.92, "90th_percentile": 10346.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10346.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9015.93, "90th_percentile": 9015.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9015.93, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25875.25, "90th_percentile": 25875.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25875.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8021.79, "90th_percentile": 8021.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8021.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 45129.89, "90th_percentile": 45129.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45129.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6192.13, "90th_percentile": 17752.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6192.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32426.74, "90th_percentile": 32426.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32426.74, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10104.2, "90th_percentile": 10174.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10104.2, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46579.67, "90th_percentile": 46579.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46579.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 14376.11, "90th_percentile": 14376.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14376.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10647.05, "90th_percentile": 10647.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10647.05, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10096.34, "90th_percentile": 10096.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10096.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8415.75, "90th_percentile": 10289.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8415.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22904.53, "90th_percentile": 22904.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22904.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "060", "type": "MS-DRG" } ], "description": "Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19749.7, "minimum": 8353.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19749.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17653.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18428.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16603.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15575.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8353.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16497.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19749.7, "90th_percentile": 19749.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19749.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6840.83, "90th_percentile": 6840.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6840.83, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17054.75, "90th_percentile": 17054.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17054.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 19268.67, "90th_percentile": 41522.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19268.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5602.41, "90th_percentile": 5602.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5602.41, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6192.13, "90th_percentile": 9637.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6192.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7673.09, "90th_percentile": 7673.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7673.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26954.93, "90th_percentile": 26954.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26954.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6840.83, "90th_percentile": 6840.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6840.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6487.0, "90th_percentile": 6487.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6487.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16977.67, "90th_percentile": 16977.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16977.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "061", "type": "MS-DRG" } ], "description": "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 59824.52, "minimum": 22621.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59824.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53474.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 55823.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50293.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47181.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22621.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49974.06 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19359.88, "90th_percentile": 21346.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20347.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21002.79, "90th_percentile": 21002.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21002.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 17091.43, "90th_percentile": 17091.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17091.43, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22222.55, "90th_percentile": 22222.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22222.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 19382.22, "90th_percentile": 19382.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19382.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19978.47, "90th_percentile": 20783.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19978.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "062", "type": "MS-DRG" } ], "description": "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 39410.88, "minimum": 14856.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39410.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35227.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36775.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33131.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31082.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14856.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32921.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 39413.1, "90th_percentile": 39413.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39413.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13674.59, "90th_percentile": 14326.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14318.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31960.15, "90th_percentile": 35229.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34980.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12792.41, "90th_percentile": 14577.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12792.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13226.35, "90th_percentile": 13226.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13226.35, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5907.32, "90th_percentile": 5907.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5907.32, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12313.55, "90th_percentile": 12313.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12313.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13184.51, "90th_percentile": 13184.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13184.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37549.09, "90th_percentile": 37549.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37549.09, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6912.86, "90th_percentile": 6912.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6912.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13364.4, "90th_percentile": 14564.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13922.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31083.83, "90th_percentile": 31083.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31083.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "063", "type": "MS-DRG" } ], "description": "Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31087.42, "minimum": 12112.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31087.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27787.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29008.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26134.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24517.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12112.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25968.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29256.51, "90th_percentile": 29256.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29256.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "064", "type": "MS-DRG" } ], "description": "Intracranial Hemorrhage Or Cerebral Infarction With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 44020.77, "minimum": 16827.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44020.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39348.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41076.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37007.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34717.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16827.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36772.49 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 24341.45, "90th_percentile": 44728.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 39307.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12863.14, "90th_percentile": 16229.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "70", "median_amount": 14484.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 14709.17, "90th_percentile": 16943.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14709.17, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18881.96, "90th_percentile": 18881.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18881.96, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19951.84, "90th_percentile": 40927.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 39071.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 18068.08, "90th_percentile": 18700.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18154.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12769.94, "90th_percentile": 16170.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 15475.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 49055.01, "90th_percentile": 67229.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49055.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8884.36, "90th_percentile": 18230.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8958.61, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30630.47, "90th_percentile": 30630.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30630.47, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6549.43, "90th_percentile": 17689.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 9819.56, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16496.34, "90th_percentile": 16496.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16496.34, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 64026.86, "90th_percentile": 64026.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64026.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 42274.95, "90th_percentile": 101107.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64428.37, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14027.85, "90th_percentile": 14901.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14526.51, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9971.43, "90th_percentile": 35303.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20242.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13126.76, "90th_percentile": 16497.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "65", "median_amount": 14968.05, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39026.11, "90th_percentile": 39026.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39026.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 24880.14, "90th_percentile": 24880.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24880.14, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14246.11, "90th_percentile": 29459.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15882.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13670.6, "90th_percentile": 16104.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 15879.26, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10938.94, "90th_percentile": 19542.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16868.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14811.74, "90th_percentile": 16977.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16494.73, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12048.21, "90th_percentile": 12048.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12048.21, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34719.5, "90th_percentile": 165023.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36716.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9245.65, "90th_percentile": 17905.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10287.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12879.13, "90th_percentile": 16135.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 14585.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32519.93, "90th_percentile": 165814.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 34719.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "065", "type": "MS-DRG" } ], "description": "Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours", "standard_charges": [ { "billing_class": "facility", "maximum": 22507.23, "minimum": 9056.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22507.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20118.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21002.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18921.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17750.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9056.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18801.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 21916.79, "90th_percentile": 23776.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22505.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6473.52, "90th_percentile": 8588.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "60", "median_amount": 7837.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 8385.09, "90th_percentile": 8385.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8385.09, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10848.27, "90th_percentile": 10848.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10848.27, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17427.74, "90th_percentile": 20977.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 19973.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6975.71, "90th_percentile": 9541.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6975.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6670.52, "90th_percentile": 8797.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 8295.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 6279.2, "90th_percentile": 20139.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11431.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5312.83, "90th_percentile": 10474.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5970.2, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5546.94, "90th_percentile": 9819.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 6598.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 14642.18, "90th_percentile": 22102.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14642.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 58503.31, "90th_percentile": 58503.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58503.31, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7204.33, "90th_percentile": 8961.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7999.36, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7289.93, "90th_percentile": 7289.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7289.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6295.59, "90th_percentile": 8610.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "59", "median_amount": 7831.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18919.42, "90th_percentile": 19950.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19545.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 7415.94, "90th_percentile": 22341.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7415.94, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8097.92, "90th_percentile": 8825.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8557.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 156731.44, "90th_percentile": 156731.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 156731.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 722.76, "90th_percentile": 8605.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8557.53, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7289.93, "90th_percentile": 10938.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7380.59, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7562.42, "90th_percentile": 7562.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7562.42, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20749.36, "90th_percentile": 20749.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20749.36, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17748.97, "90th_percentile": 18769.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 18427.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6912.86, "90th_percentile": 9541.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6998.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6594.39, "90th_percentile": 8688.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 7448.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17748.97, "90th_percentile": 18769.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17748.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "066", "type": "MS-DRG" } ], "description": "Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15232.77, "minimum": 6525.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15232.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13615.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14214.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12805.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12013.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6525.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12724.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15853.14, "90th_percentile": 16093.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16001.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4552.42, "90th_percentile": 6095.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5588.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10319.39, "90th_percentile": 10319.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10319.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11206.78, "90th_percentile": 14100.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13519.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4600.84, "90th_percentile": 4600.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4600.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5886.45, "90th_percentile": 6517.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6081.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4352.15, "90th_percentile": 11721.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4352.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 14696.01, "90th_percentile": 14696.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14696.01, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 5788.52, "90th_percentile": 6182.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5788.52, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4503.39, "90th_percentile": 6406.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6094.34, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13503.76, "90th_percentile": 13503.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13503.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 6080.5, "90th_percentile": 6080.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6080.5, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4808.08, "90th_percentile": 4808.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4808.08, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4652.25, "90th_percentile": 4652.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4652.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12013.59, "90th_percentile": 12013.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12013.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4545.39, "90th_percentile": 6141.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6124.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6821.1, "90th_percentile": 12632.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12366.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "067", "type": "MS-DRG" } ], "description": "Precerebral Occlusion Without Infarction With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32218.31, "minimum": 12616.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32218.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28798.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30063.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27085.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25409.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12616.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26913.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9618.43, "90th_percentile": 9618.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9618.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5487.24, "90th_percentile": 5487.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5487.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11895.15, "90th_percentile": 11895.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11895.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11925.57, "90th_percentile": 11925.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11925.57, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10181.11, "90th_percentile": 10181.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10181.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "068", "type": "MS-DRG" } ], "description": "Precerebral Occlusion Without Infarction Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19510.69, "minimum": 7923.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19510.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17439.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18205.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16402.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15387.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7923.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16298.14 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16263.81, "90th_percentile": 16263.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16263.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17808.37, "90th_percentile": 17808.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17808.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5800.79, "90th_percentile": 5800.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5800.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7528.47, "90th_percentile": 7548.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7528.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6062.09, "90th_percentile": 6062.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6062.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6176.07, "90th_percentile": 7528.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6274.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7528.47, "90th_percentile": 7528.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7528.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4984.74, "90th_percentile": 4984.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4984.74, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16270.73, "90th_percentile": 16270.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16270.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7767.09, "90th_percentile": 7767.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7767.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16270.73, "90th_percentile": 16270.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16270.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "069", "type": "MS-DRG" } ], "description": "Transient Ischemia Without Thrombolytic", "standard_charges": [ { "billing_class": "facility", "maximum": 17709.23, "minimum": 7413.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17709.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15829.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16524.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14887.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13966.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7413.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14793.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13771.85, "90th_percentile": 13771.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13771.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6359.83, "90th_percentile": 6953.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6760.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16683.69, "90th_percentile": 16683.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16683.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6177.8, "90th_percentile": 6932.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6926.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6842.83, "90th_percentile": 6842.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6842.83, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6179.12, "90th_percentile": 6565.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6216.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31751.15, "90th_percentile": 31751.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31751.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 6914.58, "90th_percentile": 6914.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6914.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7473.91, "90th_percentile": 7473.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7473.91, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 783.63, "90th_percentile": 6984.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5883.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13964.95, "90th_percentile": 13964.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13964.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "070", "type": "MS-DRG" } ], "description": "Other Cerebrovascular Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38479.17, "minimum": 14139.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38479.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34394.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35905.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32348.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30347.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14139.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32143.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1190.98, "90th_percentile": 13745.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8575.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32093.8, "90th_percentile": 34204.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32093.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11534.08, "90th_percentile": 18009.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12488.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21852.75, "90th_percentile": 21852.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21852.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6602.15, "90th_percentile": 6602.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6602.15, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10327.32, "90th_percentile": 13803.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 12339.74, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8914.5, "90th_percentile": 8914.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8914.5, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14538.03, "90th_percentile": 14538.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14538.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13016.46, "90th_percentile": 14161.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14121.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27862.82, "90th_percentile": 30728.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30728.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "071", "type": "MS-DRG" } ], "description": "Other Cerebrovascular Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23321.65, "minimum": 9178.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23321.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20846.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21762.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19605.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18393.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9178.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19481.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6599.3, "90th_percentile": 8857.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7696.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20848.25, "90th_percentile": 20848.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20848.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7944.39, "90th_percentile": 9026.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8829.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 10825.71, "90th_percentile": 10825.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10825.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 9056.07, "90th_percentile": 9056.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9056.07, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5259.92, "90th_percentile": 8069.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5259.92, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 22371.38, "90th_percentile": 22371.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22371.38, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8914.5, "90th_percentile": 8914.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8914.5, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6687.32, "90th_percentile": 10773.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8871.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24541.67, "90th_percentile": 24541.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24541.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 52650.83, "90th_percentile": 52650.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52650.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 6280.02, "90th_percentile": 6280.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6280.02, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8867.96, "90th_percentile": 8867.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8867.96, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5901.63, "90th_percentile": 5901.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5901.63, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9148.21, "90th_percentile": 9151.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9148.21, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18394.77, "90th_percentile": 18394.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18394.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8453.4, "90th_percentile": 8453.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8453.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1319.57, "90th_percentile": 9079.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7638.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "072", "type": "MS-DRG" } ], "description": "Other Cerebrovascular Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16600.46, "minimum": 7083.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16600.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14838.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15490.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13955.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13092.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7083.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13867.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 23872.74, "90th_percentile": 23872.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23872.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4998.09, "90th_percentile": 11270.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6085.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6819.29, "90th_percentile": 6819.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6819.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6587.26, "90th_percentile": 6587.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6587.26, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9802.65, "90th_percentile": 9802.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9802.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5785.93, "90th_percentile": 6426.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5785.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13847.19, "90th_percentile": 13847.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13847.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "073", "type": "MS-DRG" } ], "description": "Cranial And Peripheral Nerve Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34203.46, "minimum": 13669.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34203.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30573.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31916.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28754.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26975.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13669.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28571.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 33957.23, "90th_percentile": 33957.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33957.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11441.46, "90th_percentile": 11441.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11441.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18197.29, "90th_percentile": 18197.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18197.29, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19236.71, "90th_percentile": 19236.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19236.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6042.66, "90th_percentile": 6042.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6042.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12627.1, "90th_percentile": 12627.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12627.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5716.03, "90th_percentile": 37034.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8090.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10390.17, "90th_percentile": 67971.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10841.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30323.13, "90th_percentile": 30323.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30323.13, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6314.85, "90th_percentile": 6314.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6314.85, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1095.57, "90th_percentile": 1095.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1095.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8475.9, "90th_percentile": 8475.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8475.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12651.59, "90th_percentile": 13401.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12651.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "074", "type": "MS-DRG" } ], "description": "Cranial And Peripheral Nerve Disorders Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 23069.35, "minimum": 9215.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23069.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20620.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21526.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19393.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18194.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9215.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19270.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 19590.87, "90th_percentile": 24618.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21301.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5917.84, "90th_percentile": 8804.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7990.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 6657.59, "90th_percentile": 6657.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6657.59, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6314.85, "90th_percentile": 6314.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6314.85, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18970.76, "90th_percentile": 21736.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 20474.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4814.4, "90th_percentile": 4814.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4814.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7094.24, "90th_percentile": 9034.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8538.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5171.65, "90th_percentile": 5171.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5171.65, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4472.1, "90th_percentile": 9719.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5716.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 37739.02, "90th_percentile": 37739.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37739.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6596.98, "90th_percentile": 8928.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7385.88, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20450.85, "90th_percentile": 20450.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20450.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8229.37, "90th_percentile": 8229.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8229.37, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 9825.42, "90th_percentile": 9825.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9825.42, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6314.85, "90th_percentile": 8938.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8938.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7419.54, "90th_percentile": 7419.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7419.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18194.05, "90th_percentile": 18194.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18194.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5988.22, "90th_percentile": 5988.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5988.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 998.59, "90th_percentile": 8868.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7142.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19240.62, "90th_percentile": 19240.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19240.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "075", "type": "MS-DRG" } ], "description": "Viral Meningitis With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38118.43, "minimum": 16101.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38118.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34072.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35569.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32045.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30062.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16101.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31842.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10848.57, "90th_percentile": 10848.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10848.57, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13918.64, "90th_percentile": 13918.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13918.64, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "076", "type": "MS-DRG" } ], "description": "Viral Meningitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20291.91, "minimum": 7618.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20291.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18138.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18934.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17058.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16003.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7618.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16950.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 18859.87, "90th_percentile": 18859.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18859.87, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16924.14, "90th_percentile": 16924.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16924.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "077", "type": "MS-DRG" } ], "description": "Hypertensive Encephalopathy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34218.95, "minimum": 26987.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34218.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30586.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31930.58 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28767.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26987.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28584.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "078", "type": "MS-DRG" } ], "description": "Hypertensive Encephalopathy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22082.31, "minimum": 17415.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22082.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19738.48 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20605.57 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18564.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17415.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18446.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "079", "type": "MS-DRG" } ], "description": "Hypertensive Encephalopathy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14754.74, "minimum": 11636.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14754.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13188.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13768.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12403.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11636.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12325.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19372.33, "90th_percentile": 19372.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19372.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12429.2, "90th_percentile": 12429.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12429.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6693.09, "90th_percentile": 6693.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6693.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "080", "type": "MS-DRG" } ], "description": "Nontraumatic Stupor And Coma With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43992.0, "minimum": 15266.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43992.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39322.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41050.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36983.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34695.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15266.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36748.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14830.74, "90th_percentile": 14830.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14830.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38554.09, "90th_percentile": 38554.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38554.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5647.25, "90th_percentile": 5647.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5647.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13745.88, "90th_percentile": 13745.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13745.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 83859.23, "90th_percentile": 83859.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83859.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8151.22, "90th_percentile": 8151.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8151.22, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14632.67, "90th_percentile": 14632.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14632.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "081", "type": "MS-DRG" } ], "description": "Nontraumatic Stupor And Coma Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20024.13, "minimum": 8165.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20024.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17898.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18685.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16833.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15792.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8165.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16727.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7859.23, "90th_percentile": 7859.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7859.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6040.53, "90th_percentile": 6040.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6040.53, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16700.8, "90th_percentile": 16700.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16700.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "082", "type": "MS-DRG" } ], "description": "Traumatic Stupor And Coma >1 Hour With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 51346.13, "minimum": 18960.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51346.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45896.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47912.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43165.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40495.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18960.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42891.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14892.66, "90th_percentile": 16760.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 16112.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 17415.65, "90th_percentile": 17415.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17415.65, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16835.3, "90th_percentile": 16835.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16835.3, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40964.46, "90th_percentile": 45573.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40964.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14024.49, "90th_percentile": 18412.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16724.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9247.94, "90th_percentile": 9247.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9247.94, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 50429.55, "90th_percentile": 50429.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50429.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 15432.92, "90th_percentile": 15432.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15432.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16991.03, "90th_percentile": 20487.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18378.61, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 442352.02, "90th_percentile": 442352.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 442352.02, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17746.57, "90th_percentile": 17746.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17746.57, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13908.32, "90th_percentile": 13908.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13908.32, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17507.93, "90th_percentile": 17507.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17507.93, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46029.06, "90th_percentile": 46029.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46029.06, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11470.1, "90th_percentile": 11470.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11470.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17731.41, "90th_percentile": 18563.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18546.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "083", "type": "MS-DRG" } ], "description": "Traumatic Stupor And Coma >1 Hour With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 30768.73, "minimum": 12050.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30768.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27502.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28711.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25866.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24266.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12050.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25702.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9423.01, "90th_percentile": 11381.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 10381.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 107.45, "90th_percentile": 107.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 107.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5782.79, "90th_percentile": 5782.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5782.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10099.51, "90th_percentile": 10099.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10099.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 27332.72, "90th_percentile": 27332.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27332.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 11578.43, "90th_percentile": 11578.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11578.43, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9798.4, "90th_percentile": 11405.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10435.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26575.06, "90th_percentile": 26575.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26575.06, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 11447.53, "90th_percentile": 11447.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11447.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11413.32, "90th_percentile": 12508.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11413.32, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10139.37, "90th_percentile": 10139.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10139.37, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5730.69, "90th_percentile": 5730.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5730.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11469.32, "90th_percentile": 11539.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11487.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25664.0, "90th_percentile": 25664.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25664.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "084", "type": "MS-DRG" } ], "description": "Traumatic Stupor And Coma >1 Hour Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21157.24, "minimum": 8633.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21157.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18911.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19742.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17786.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16686.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8633.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17673.57 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5522.22, "90th_percentile": 5522.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5522.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34194.53, "90th_percentile": 34194.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34194.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5470.21, "90th_percentile": 5470.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5470.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6133.94, "90th_percentile": 6133.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6133.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8100.27, "90th_percentile": 8100.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8100.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13158.82, "90th_percentile": 13158.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13158.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "085", "type": "MS-DRG" } ], "description": "Traumatic Stupor And Coma <1 Hour With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 50146.63, "minimum": 18853.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50146.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44824.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46793.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42157.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39549.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18853.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41889.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14803.92, "90th_percentile": 17975.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 16990.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34124.05, "90th_percentile": 44508.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34124.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15843.55, "90th_percentile": 18304.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16286.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4098.37, "90th_percentile": 4098.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4098.37, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9247.94, "90th_percentile": 9247.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9247.94, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14067.66, "90th_percentile": 14067.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14067.66, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15056.04, "90th_percentile": 15056.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15056.04, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 10307.44, "90th_percentile": 10307.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10307.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15763.27, "90th_percentile": 18502.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16982.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 16448.84, "90th_percentile": 16448.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16448.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 16369.61, "90th_percentile": 19732.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18029.18, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17076.46, "90th_percentile": 17076.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17076.46, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17500.31, "90th_percentile": 18125.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18122.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39550.76, "90th_percentile": 39550.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39550.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "086", "type": "MS-DRG" } ], "description": "Traumatic Stupor And Coma <1 Hour With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 29027.02, "minimum": 11327.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29027.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25946.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27085.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24402.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22892.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11327.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24247.55 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18572.05, "90th_percentile": 18572.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18572.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9199.73, "90th_percentile": 10103.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 9737.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 10056.51, "90th_percentile": 10056.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10056.51, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24820.58, "90th_percentile": 40829.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24820.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9129.89, "90th_percentile": 10875.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 10772.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5502.68, "90th_percentile": 9247.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5502.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 9308.75, "90th_percentile": 10276.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9308.75, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7481.42, "90th_percentile": 10785.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 9208.87, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16937.38, "90th_percentile": 16937.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16937.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8861.1, "90th_percentile": 10798.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8861.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10809.61, "90th_percentile": 10809.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10809.61, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7354.84, "90th_percentile": 10905.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9400.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24209.51, "90th_percentile": 24209.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24209.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "087", "type": "MS-DRG" } ], "description": "Traumatic Stupor And Coma <1 Hour Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19563.8, "minimum": 8313.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19563.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17487.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18255.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16446.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15429.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8313.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16342.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7427.51, "90th_percentile": 7427.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7427.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12878.39, "90th_percentile": 12878.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12878.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5782.79, "90th_percentile": 5782.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5782.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6842.0, "90th_percentile": 7595.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7061.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7597.69, "90th_percentile": 7597.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7597.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16316.87, "90th_percentile": 16316.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16316.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6995.92, "90th_percentile": 6995.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6995.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "088", "type": "MS-DRG" } ], "description": "Concussion With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31217.99, "minimum": 11708.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31217.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27904.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29130.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26244.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24620.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11708.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26077.76 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10542.8, "90th_percentile": 10542.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10542.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9265.47, "90th_percentile": 9265.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9265.47, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27676.52, "90th_percentile": 27676.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27676.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10066.46, "90th_percentile": 10066.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10066.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "089", "type": "MS-DRG" } ], "description": "Concussion With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23726.65, "minimum": 9742.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23726.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21208.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22139.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19946.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18712.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9742.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19819.91 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22074.54, "90th_percentile": 22074.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22074.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6686.96, "90th_percentile": 6686.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6686.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8997.3, "90th_percentile": 9034.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8997.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8947.08, "90th_percentile": 8947.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8947.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2466.0, "90th_percentile": 2466.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2466.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "090", "type": "MS-DRG" } ], "description": "Concussion Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18970.69, "minimum": 7603.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18970.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16957.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17702.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15948.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14961.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7603.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15847.06 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16959.11, "90th_percentile": 16959.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16959.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5095.78, "90th_percentile": 5095.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5095.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "091", "type": "MS-DRG" } ], "description": "Other Disorders Of Nervous System With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40340.39, "minimum": 14848.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40340.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36058.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37642.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33913.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31815.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14848.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33698.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9188.04, "90th_percentile": 16347.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14086.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 13522.9, "90th_percentile": 13522.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13522.9, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10758.29, "90th_percentile": 10758.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10758.29, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36181.23, "90th_percentile": 36181.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36181.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12979.36, "90th_percentile": 14628.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13799.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 5731.52, "90th_percentile": 21010.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5731.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5014.74, "90th_percentile": 5014.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5014.74, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16958.9, "90th_percentile": 41023.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16958.9, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13406.63, "90th_percentile": 13406.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13406.63, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 10758.29, "90th_percentile": 25931.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10758.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8446.78, "90th_percentile": 14726.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13869.28, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35069.53, "90th_percentile": 35069.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35069.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 28898.4, "90th_percentile": 28898.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28898.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13878.12, "90th_percentile": 13878.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13878.12, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15294.95, "90th_percentile": 15294.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15294.95, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31816.9, "90th_percentile": 31816.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31816.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11544.61, "90th_percentile": 14690.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13452.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31816.9, "90th_percentile": 33647.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33647.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "092", "type": "MS-DRG" } ], "description": "Other Disorders Of Nervous System With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23432.3, "minimum": 9155.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23432.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20945.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21865.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19698.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18480.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9155.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19574.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7002.62, "90th_percentile": 9987.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8865.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7533.69, "90th_percentile": 7533.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7533.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20794.99, "90th_percentile": 323473.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20850.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5560.49, "90th_percentile": 5560.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5560.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7582.87, "90th_percentile": 8922.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8635.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 11062.48, "90th_percentile": 28433.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14308.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8810.67, "90th_percentile": 8810.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8810.67, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21588.2, "90th_percentile": 21588.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21588.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4703.75, "90th_percentile": 6901.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5259.92, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 22234.91, "90th_percentile": 22234.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22234.91, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 10012.62, "90th_percentile": 10012.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10012.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6388.8, "90th_percentile": 8883.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8861.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20070.24, "90th_percentile": 20770.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20770.64, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8864.83, "90th_percentile": 8864.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8864.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 9291.48, "90th_percentile": 9291.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9291.48, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6405.52, "90th_percentile": 10758.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7533.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9189.56, "90th_percentile": 9189.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9189.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18478.55, "90th_percentile": 18478.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18478.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7270.17, "90th_percentile": 8945.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7963.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17082.24, "90th_percentile": 19541.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18478.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "093", "type": "MS-DRG" } ], "description": "Other Disorders Of Nervous System Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17468.0, "minimum": 7394.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17468.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15613.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16299.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14684.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13776.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7394.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14591.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17451.42, "90th_percentile": 18618.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17517.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5877.78, "90th_percentile": 5877.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5877.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2687.48, "90th_percentile": 2687.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2687.48, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16458.48, "90th_percentile": 345396.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16458.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6529.3, "90th_percentile": 6529.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6529.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 9434.73, "90th_percentile": 9434.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9434.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7273.91, "90th_percentile": 7273.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7273.91, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4703.75, "90th_percentile": 6901.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5921.37, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7533.69, "90th_percentile": 7533.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7533.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5238.05, "90th_percentile": 6892.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6378.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15485.28, "90th_percentile": 15485.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15485.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13776.44, "90th_percentile": 13776.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13776.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7064.22, "90th_percentile": 7064.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7064.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13776.44, "90th_percentile": 14311.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13776.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "094", "type": "MS-DRG" } ], "description": "Bacterial And Tuberculous Infections Of Nervous System With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 80742.74, "minimum": 28541.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80742.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 72172.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 75343.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67878.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63679.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28541.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67447.97 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 127265.57, "90th_percentile": 127265.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 127265.57, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26838.65, "90th_percentile": 26838.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26838.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16262.69, "90th_percentile": 16262.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16262.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 72178.58, "90th_percentile": 72178.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72178.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28385.27, "90th_percentile": 28385.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28385.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25210.18, "90th_percentile": 28480.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25210.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 67884.06, "90th_percentile": 67884.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67884.06, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 27653.23, "90th_percentile": 27653.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27653.23, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36876.57, "90th_percentile": 36876.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36876.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27097.58, "90th_percentile": 27097.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27097.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "095", "type": "MS-DRG" } ], "description": "Bacterial And Tuberculous Infections Of Nervous System With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 53048.01, "minimum": 21240.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53048.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 47417.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 49500.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44596.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41837.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44313.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 53052.43, "90th_percentile": 56048.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53052.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16919.54, "90th_percentile": 16919.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16919.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18138.42, "90th_percentile": 18138.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18138.42, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 53781.48, "90th_percentile": 53781.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53781.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16832.7, "90th_percentile": 16832.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16832.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6232.95, "90th_percentile": 6232.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6232.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 16325.25, "90th_percentile": 16325.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16325.25, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6917.08, "90th_percentile": 6917.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6917.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29566.2, "90th_percentile": 29566.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29566.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7266.21, "90th_percentile": 7266.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7266.21, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 169307.21, "90th_percentile": 169307.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 169307.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17420.67, "90th_percentile": 17420.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17420.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "096", "type": "MS-DRG" } ], "description": "Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 53048.01, "minimum": 21240.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53048.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 47417.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 49500.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44596.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41837.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21240.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44313.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47085.8, "90th_percentile": 47085.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47085.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18961.3, "90th_percentile": 18961.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18961.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41840.73, "90th_percentile": 41840.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41840.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "097", "type": "MS-DRG" } ], "description": "Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 79335.21, "minimum": 29259.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79335.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70914.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 74029.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66695.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62569.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29259.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66272.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25381.77, "90th_percentile": 25381.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25381.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 78574.87, "90th_percentile": 78574.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78574.87, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33995.94, "90th_percentile": 70408.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 70408.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10411.99, "90th_percentile": 10411.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10411.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27914.25, "90th_percentile": 27914.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27914.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 122171.57, "90th_percentile": 122171.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 122171.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27960.25, "90th_percentile": 27960.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27960.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31997.25, "90th_percentile": 31997.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31997.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 27902.46, "90th_percentile": 27902.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27902.46, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11321.0, "90th_percentile": 11321.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11321.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "098", "type": "MS-DRG" } ], "description": "Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 48004.35, "minimum": 19032.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48004.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42909.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44794.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40356.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37859.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19032.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40100.15 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15706.64, "90th_percentile": 15706.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15706.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27364.34, "90th_percentile": 42913.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42609.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19139.03, "90th_percentile": 21061.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19139.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 33704.25, "90th_percentile": 33704.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33704.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 19612.44, "90th_percentile": 19612.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19612.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42559.5, "90th_percentile": 42559.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42559.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 1641.75, "90th_percentile": 1641.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1641.75, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19612.44, "90th_percentile": 19612.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19612.44, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10318.19, "90th_percentile": 10318.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10318.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37862.96, "90th_percentile": 37862.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37862.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "099", "type": "MS-DRG" } ], "description": "Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 30832.91, "minimum": 11790.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30832.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27560.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28770.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25920.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24316.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11790.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25756.09 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11391.45, "90th_percentile": 11391.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11391.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26189.07, "90th_percentile": 27367.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26262.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11418.69, "90th_percentile": 11418.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11418.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 20306.52, "90th_percentile": 20306.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20306.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 41103.35, "90th_percentile": 41103.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41103.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26728.93, "90th_percentile": 26728.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26728.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9647.45, "90th_percentile": 9647.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9647.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24318.66, "90th_percentile": 25717.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24318.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "100", "type": "MS-DRG" } ], "description": "Seizures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43934.46, "minimum": 16251.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43934.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39271.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40996.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36934.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34649.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16251.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36700.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 46418.3, "90th_percentile": 46418.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46418.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8480.91, "90th_percentile": 15864.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 14200.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 15093.04, "90th_percentile": 15093.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15093.04, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33328.83, "90th_percentile": 41397.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 38805.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 14401.67, "90th_percentile": 14401.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14401.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14210.64, "90th_percentile": 15960.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 15868.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 33204.89, "90th_percentile": 35096.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33204.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 12400.01, "90th_percentile": 12400.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12400.01, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4308.23, "90th_percentile": 7071.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 7029.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14354.88, "90th_percentile": 14354.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14354.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40198.65, "90th_percentile": 40198.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40198.65, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 88191.13, "90th_percentile": 88191.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 88191.13, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7766.0, "90th_percentile": 15050.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7766.0, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14158.99, "90th_percentile": 15939.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15687.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36352.52, "90th_percentile": 38775.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36352.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7311.67, "90th_percentile": 14134.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7311.67, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5876.27, "90th_percentile": 18881.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15050.4, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14721.02, "90th_percentile": 16423.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14788.26, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 96073.49, "90th_percentile": 96073.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 96073.49, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32456.09, "90th_percentile": 187389.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34651.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7364.31, "90th_percentile": 7364.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7364.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7753.28, "90th_percentile": 16078.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 14527.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34651.43, "90th_percentile": 35749.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34651.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "101", "type": "MS-DRG" } ], "description": "Seizures Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20395.93, "minimum": 8220.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20395.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18231.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19031.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17146.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16085.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17037.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15570.69, "90th_percentile": 21103.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 20318.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5759.12, "90th_percentile": 7984.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 7177.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18651.0, "90th_percentile": 18651.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18651.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4772.9, "90th_percentile": 5785.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5761.58, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12804.64, "90th_percentile": 18821.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 16814.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4567.17, "90th_percentile": 7431.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4567.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6177.51, "90th_percentile": 7881.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 6189.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 15745.81, "90th_percentile": 20604.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15745.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4608.32, "90th_percentile": 6434.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 4738.21, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12861.31, "90th_percentile": 22944.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12861.31, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3856.53, "90th_percentile": 5236.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 5236.97, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38282.67, "90th_percentile": 38282.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38282.67, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 17954.1, "90th_percentile": 20033.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19197.88, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 28117.05, "90th_percentile": 28117.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28117.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5785.6, "90th_percentile": 7766.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5785.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5690.34, "90th_percentile": 7881.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 7245.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15723.95, "90th_percentile": 18082.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 17148.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7841.48, "90th_percentile": 7864.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7841.48, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5785.6, "90th_percentile": 7766.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5785.6, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5819.68, "90th_percentile": 6540.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6476.29, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12895.34, "90th_percentile": 12895.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12895.34, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14651.37, "90th_percentile": 17012.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 16087.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4526.03, "90th_percentile": 5572.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5486.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6100.2, "90th_percentile": 7924.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 6971.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14558.29, "90th_percentile": 16660.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 16087.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "102", "type": "MS-DRG" } ], "description": "Headaches With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25658.68, "minimum": 9915.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25658.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22935.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23942.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21570.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20236.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9915.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21433.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9287.18, "90th_percentile": 9287.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9287.18, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17946.35, "90th_percentile": 17946.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17946.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9625.13, "90th_percentile": 9625.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9625.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5629.21, "90th_percentile": 5629.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5629.21, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6221.75, "90th_percentile": 6221.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6221.75, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8836.52, "90th_percentile": 8836.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8836.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9367.25, "90th_percentile": 9367.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9367.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4223.69, "90th_percentile": 4223.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4223.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21402.05, "90th_percentile": 21402.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21402.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "103", "type": "MS-DRG" } ], "description": "Headaches Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18815.78, "minimum": 7705.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18815.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16818.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17557.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15817.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14839.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7705.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15717.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18327.72, "90th_percentile": 19553.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19553.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5623.87, "90th_percentile": 5623.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5623.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18797.92, "90th_percentile": 19878.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18797.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6358.22, "90th_percentile": 6358.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6358.22, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14069.96, "90th_percentile": 17336.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 16203.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4848.18, "90th_percentile": 10294.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10294.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5455.11, "90th_percentile": 7317.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6528.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 15378.17, "90th_percentile": 15378.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15378.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4891.86, "90th_percentile": 4891.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4891.86, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15.05, "90th_percentile": 15.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15.05, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5755.28, "90th_percentile": 6221.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5755.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23886.96, "90th_percentile": 23886.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23886.96, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 15708.4, "90th_percentile": 18479.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17557.48, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5148.13, "90th_percentile": 7301.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7033.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15817.97, "90th_percentile": 16680.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16407.37, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7017.78, "90th_percentile": 7017.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7017.78, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5066.57, "90th_percentile": 6448.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5066.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14839.39, "90th_percentile": 14839.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14839.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5445.48, "90th_percentile": 7409.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5600.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12089.39, "90th_percentile": 16034.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14839.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "113", "type": "MS-DRG" } ], "description": "Orbital Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 49940.81, "minimum": 19468.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49940.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44640.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46601.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41984.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39386.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19468.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41717.76 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16303.25, "90th_percentile": 16312.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16303.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44324.14, "90th_percentile": 44324.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44324.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17906.28, "90th_percentile": 17906.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17906.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15537.25, "90th_percentile": 15537.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15537.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 110.0, "90th_percentile": 110.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18061.96, "90th_percentile": 18061.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18061.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "114", "type": "MS-DRG" } ], "description": "Orbital Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 26161.06, "minimum": 11717.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26161.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23384.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24411.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21992.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20632.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11717.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21853.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22411.81, "90th_percentile": 22411.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22411.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "115", "type": "MS-DRG" } ], "description": "Extraocular Procedures Except Orbit", "standard_charges": [ { "billing_class": "facility", "maximum": 33880.35, "minimum": 13130.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33880.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30284.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31614.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28482.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26720.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13130.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28301.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11350.97, "90th_percentile": 11350.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11350.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12540.17, "90th_percentile": 12540.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12540.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "116", "type": "MS-DRG" } ], "description": "Intraocular Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36925.57, "minimum": 15251.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36925.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33006.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34456.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31042.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29122.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15251.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30845.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 121351.49, "90th_percentile": 121351.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121351.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "117", "type": "MS-DRG" } ], "description": "Intraocular Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 23870.5, "minimum": 9635.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23870.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21336.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22274.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20067.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18825.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9635.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19940.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20597.74, "90th_percentile": 20597.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20597.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8181.46, "90th_percentile": 8181.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8181.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "121", "type": "MS-DRG" } ], "description": "Acute Major Eye Infections With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25740.57, "minimum": 10244.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25740.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23008.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24019.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21639.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20300.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10244.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21502.23 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11435.28, "90th_percentile": 11435.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11435.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6216.36, "90th_percentile": 6216.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6216.36, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4820.1, "90th_percentile": 4820.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4820.1, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20302.49, "90th_percentile": 20302.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20302.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "122", "type": "MS-DRG" } ], "description": "Acute Major Eye Infections Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15011.46, "minimum": 7312.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15011.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13418.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14007.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12619.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11839.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7312.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12539.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "123", "type": "MS-DRG" } ], "description": "Neurological Eye Disorders", "standard_charges": [ { "billing_class": "facility", "maximum": 17775.62, "minimum": 7412.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17775.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15888.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16586.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14943.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14019.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7412.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14848.76 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16053.96, "90th_percentile": 16053.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16053.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12806.3, "90th_percentile": 12806.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12806.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18779.62, "90th_percentile": 18779.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18779.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9825.85, "90th_percentile": 9825.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9825.85, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13398.66, "90th_percentile": 13398.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13398.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6971.58, "90th_percentile": 6971.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6971.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7116.01, "90th_percentile": 7116.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7116.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5827.84, "90th_percentile": 5827.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5827.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 32998.43, "90th_percentile": 32998.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32998.43, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 5648.76, "90th_percentile": 5648.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5648.76, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15667.73, "90th_percentile": 15667.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15667.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 569.33, "90th_percentile": 569.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 569.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6438.37, "90th_percentile": 6438.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6438.37, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5049.63, "90th_percentile": 5049.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5049.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13624.08, "90th_percentile": 13624.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13624.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "124", "type": "MS-DRG" } ], "description": "Other Disorders Of The Eye With Mcc Or Thrombolytic Agent", "standard_charges": [ { "billing_class": "facility", "maximum": 28854.4, "minimum": 11485.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28854.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25791.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26924.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24257.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22756.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11485.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24103.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10718.2, "90th_percentile": 10718.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10718.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11260.28, "90th_percentile": 11260.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11260.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7861.83, "90th_percentile": 7861.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7861.83, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11260.28, "90th_percentile": 11260.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11260.28, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11259.25, "90th_percentile": 11259.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11259.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "125", "type": "MS-DRG" } ], "description": "Other Disorders Of The Eye Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18273.57, "minimum": 7173.19, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18273.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16334.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17051.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15362.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14411.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7173.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15264.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7110.82, "90th_percentile": 7131.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7110.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16218.4, "90th_percentile": 16218.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16218.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7285.22, "90th_percentile": 7285.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7285.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4742.41, "90th_percentile": 4742.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4742.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 3131.99, "90th_percentile": 3131.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3131.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4902.17, "90th_percentile": 4902.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4902.17, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6023.94, "90th_percentile": 6023.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6023.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8685.45, "90th_percentile": 8685.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8685.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7172.86, "90th_percentile": 7172.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7172.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "135", "type": "MS-DRG" } ], "description": "Sinus And Mastoid Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 53355.63, "minimum": 18062.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53355.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 47692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 49787.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44854.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42079.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18062.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44570.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17169.43, "90th_percentile": 17169.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17169.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 23620.37, "90th_percentile": 23620.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23620.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6844.93, "90th_percentile": 6844.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6844.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17981.28, "90th_percentile": 17981.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17981.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "136", "type": "MS-DRG" } ], "description": "Sinus And Mastoid Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21648.54, "minimum": 9095.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21648.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19350.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20200.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18199.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17073.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9095.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18083.98 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "137", "type": "MS-DRG" } ], "description": "Mouth Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 30950.2, "minimum": 12806.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30950.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27665.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28880.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26019.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24409.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12806.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25854.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10932.36, "90th_percentile": 10932.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10932.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24411.16, "90th_percentile": 24411.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24411.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "138", "type": "MS-DRG" } ], "description": "Mouth Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18003.57, "minimum": 8092.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18003.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16799.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15135.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14198.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8092.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15039.17 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "139", "type": "MS-DRG" } ], "description": "Salivary Gland Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 30383.65, "minimum": 10806.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30383.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27158.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28351.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25542.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23962.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10806.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25380.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 973.22, "90th_percentile": 973.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 973.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9585.83, "90th_percentile": 9585.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9585.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "399", "type": "MS-DRG" } ], "description": "Appendix Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24877.46, "minimum": 10100.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24877.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22236.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23213.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20913.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19620.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10100.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20781.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22940.54, "90th_percentile": 44569.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24870.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9818.84, "90th_percentile": 9818.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9818.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21839.54, "90th_percentile": 22231.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21839.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 34264.6, "90th_percentile": 34264.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34264.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5603.48, "90th_percentile": 5603.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5603.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 23967.52, "90th_percentile": 23967.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23967.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7380.66, "90th_percentile": 7380.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7380.66, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9215.18, "90th_percentile": 9215.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9215.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22047.83, "90th_percentile": 22047.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22047.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6190.51, "90th_percentile": 6190.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6190.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18878.31, "90th_percentile": 19614.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18878.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10010.49, "90th_percentile": 10010.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10010.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20628.87, "90th_percentile": 20628.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20628.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "402", "type": "MS-DRG" } ], "description": "Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical", "standard_charges": [ { "billing_class": "facility", "maximum": 86957.13, "minimum": 32433.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86957.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77727.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 81141.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73102.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68580.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32433.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72639.12 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 73793.44, "90th_percentile": 102772.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84985.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28742.58, "90th_percentile": 31313.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 30383.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 86341.2, "90th_percentile": 86341.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 86341.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22747.07, "90th_percentile": 29069.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22747.07, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74744.43, "90th_percentile": 82830.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 76844.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 27729.59, "90th_percentile": 27729.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27729.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27470.76, "90th_percentile": 30497.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30254.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 29966.1, "90th_percentile": 29966.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29966.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 33475.99, "90th_percentile": 33475.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33475.99, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 55215.25, "90th_percentile": 55215.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55215.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 20590.02, "90th_percentile": 26230.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 26230.69, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 132422.31, "90th_percentile": 132422.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 132422.31, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 28778.52, "90th_percentile": 28778.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28778.52, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 28978.67, "90th_percentile": 28978.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28978.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28670.75, "90th_percentile": 31536.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 30393.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 81871.9, "90th_percentile": 112350.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 97511.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 30388.78, "90th_percentile": 30388.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30388.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22747.07, "90th_percentile": 29069.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22747.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 120.64, "90th_percentile": 106858.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 91446.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 21570.49, "90th_percentile": 27479.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27479.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28906.8, "90th_percentile": 30701.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 30075.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 90998.9, "90th_percentile": 107374.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 92621.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "405", "type": "MS-DRG" } ], "description": "Pancreas, Liver And Shunt Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 120135.92, "minimum": 43693.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 120135.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 107384.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 112101.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100995.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94747.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43693.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 100354.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 120142.56, "90th_percentile": 120142.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 120142.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34712.59, "90th_percentile": 55273.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38550.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42553.43, "90th_percentile": 42553.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42553.43, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 112703.24, "90th_percentile": 357545.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 257552.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 20896.17, "90th_percentile": 20896.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20896.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30966.8, "90th_percentile": 75659.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41865.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 68464.15, "90th_percentile": 153750.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68464.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 34775.54, "90th_percentile": 34775.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34775.54, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 80310.8, "90th_percentile": 80310.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80310.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 18109.99, "90th_percentile": 38436.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22662.32, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 299697.52, "90th_percentile": 299697.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 299697.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 40427.65, "90th_percentile": 40427.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40427.65, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 35669.42, "90th_percentile": 35669.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35669.42, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39388.73, "90th_percentile": 83093.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40932.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 220152.69, "90th_percentile": 220152.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 220152.69, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 29900.78, "90th_percentile": 29900.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29900.78, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17413.63, "90th_percentile": 17413.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17413.63, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 43719.96, "90th_percentile": 43719.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43719.96, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 133626.34, "90th_percentile": 232820.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 133626.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 20707.92, "90th_percentile": 20707.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20707.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38179.83, "90th_percentile": 42223.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 40290.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 105197.17, "90th_percentile": 657595.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 198227.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "406", "type": "MS-DRG" } ], "description": "Pancreas, Liver And Shunt Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 62148.27, "minimum": 23733.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62148.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 55551.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 57992.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52246.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49014.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23733.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51915.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 181284.64, "90th_percentile": 181284.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 181284.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19987.89, "90th_percentile": 22144.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 20174.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 55162.59, "90th_percentile": 271294.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59749.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13215.02, "90th_percentile": 13215.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13215.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20417.93, "90th_percentile": 23056.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22028.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 52465.59, "90th_percentile": 52465.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52465.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 16813.16, "90th_percentile": 16813.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16813.16, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15762.34, "90th_percentile": 19766.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15762.34, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 98325.0, "90th_percentile": 98325.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 98325.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 186541.19, "90th_percentile": 186541.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 186541.19, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 125142.73, "90th_percentile": 125142.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 125142.73, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 20970.18, "90th_percentile": 20970.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20970.18, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 13810.29, "90th_percentile": 13810.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13810.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19723.14, "90th_percentile": 23100.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22124.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 221553.21, "90th_percentile": 221553.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 221553.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 22060.42, "90th_percentile": 22060.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22060.42, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 51837.45, "90th_percentile": 51837.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51837.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22251.55, "90th_percentile": 23265.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22415.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 66074.16, "90th_percentile": 145726.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66074.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "407", "type": "MS-DRG" } ], "description": "Pancreas, Liver And Shunt Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 47262.96, "minimum": 18447.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47262.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42246.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44102.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39732.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37274.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18447.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39480.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 61978.8, "90th_percentile": 61978.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61978.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15506.69, "90th_percentile": 17000.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15506.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42250.4, "90th_percentile": 42250.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42250.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13215.02, "90th_percentile": 13215.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13215.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16676.72, "90th_percentile": 16676.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16676.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 44106.41, "90th_percentile": 44106.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44106.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17047.97, "90th_percentile": 17047.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17047.97, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 32005.79, "90th_percentile": 32005.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32005.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37278.25, "90th_percentile": 37278.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37278.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17258.86, "90th_percentile": 17258.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17258.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37278.25, "90th_percentile": 40969.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40969.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "408", "type": "MS-DRG" } ], "description": "Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 77482.84, "minimum": 28900.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77482.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69258.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 72301.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65137.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61108.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28900.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64724.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38495.53, "90th_percentile": 38495.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38495.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10507.42, "90th_percentile": 10507.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10507.42, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27730.2, "90th_percentile": 27730.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27730.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "409", "type": "MS-DRG" } ], "description": "Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 46393.22, "minimum": 18119.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46393.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41469.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43290.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39001.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36588.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18119.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38754.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17339.19, "90th_percentile": 17339.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17339.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14924.55, "90th_percentile": 14924.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14924.55, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16726.75, "90th_percentile": 16726.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16726.75, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10044.36, "90th_percentile": 10044.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10044.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15103.89, "90th_percentile": 15103.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15103.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "410", "type": "MS-DRG" } ], "description": "Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34325.18, "minimum": 13540.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34325.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30681.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32029.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28856.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27071.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13540.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28673.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7527.22, "90th_percentile": 7527.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7527.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "411", "type": "MS-DRG" } ], "description": "Cholecystectomy With C.D.E. With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 60559.27, "minimum": 26863.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60559.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 54131.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 56509.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50910.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47761.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26863.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50587.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 24543.05, "90th_percentile": 24543.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24543.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "412", "type": "MS-DRG" } ], "description": "Cholecystectomy With C.D.E. With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 47172.23, "minimum": 17538.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47172.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42165.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44017.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39656.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37203.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17538.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39405.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "413", "type": "MS-DRG" } ], "description": "Cholecystectomy With C.D.E. Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36790.57, "minimum": 14105.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36790.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32885.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34330.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30928.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29015.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14105.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30732.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "414", "type": "MS-DRG" } ], "description": "Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 77538.17, "minimum": 28877.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77538.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69308.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 72352.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65184.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61151.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28877.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64771.05 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24915.4, "90th_percentile": 24915.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24915.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25580.07, "90th_percentile": 25580.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25580.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 193520.8, "90th_percentile": 193520.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 193520.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25994.89, "90th_percentile": 25994.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25994.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "415", "type": "MS-DRG" } ], "description": "Cholecystectomy Except By Laparoscope Without C.D.E. With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 43775.12, "minimum": 17260.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43775.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39128.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40847.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36800.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34524.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17260.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36567.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8591.91, "90th_percentile": 8591.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8591.91, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36802.55, "90th_percentile": 36802.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36802.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36511.77, "90th_percentile": 36511.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36511.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14924.99, "90th_percentile": 14924.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14924.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "416", "type": "MS-DRG" } ], "description": "Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 30323.9, "minimum": 11797.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30323.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27105.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28296.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25492.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23915.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11797.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25330.89 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30295.12, "90th_percentile": 30295.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30295.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11218.22, "90th_percentile": 11218.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11218.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10463.25, "90th_percentile": 10463.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10463.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "417", "type": "MS-DRG" } ], "description": "Laparoscopic Cholecystectomy Without C.D.E. With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 52594.32, "minimum": 19742.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52594.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 47011.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 49077.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44214.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41479.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19742.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43934.36 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 52544.42, "90th_percentile": 54534.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52594.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17120.86, "90th_percentile": 18833.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 18593.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9492.01, "90th_percentile": 9492.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9492.01, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44825.88, "90th_percentile": 49554.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 46679.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17110.52, "90th_percentile": 19179.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18572.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 37215.79, "90th_percentile": 37215.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37215.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8591.91, "90th_percentile": 10507.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 10507.42, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44234.39, "90th_percentile": 44234.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44234.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 51868.4, "90th_percentile": 76408.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51868.4, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 19152.74, "90th_percentile": 19152.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19152.74, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16661.9, "90th_percentile": 18887.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 18821.32, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42532.43, "90th_percentile": 64106.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44214.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 75937.86, "90th_percentile": 75937.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75937.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 18893.52, "90th_percentile": 18893.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18893.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11608.2, "90th_percentile": 16581.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11608.2, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37582.13, "90th_percentile": 37582.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37582.13, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41479.43, "90th_percentile": 44021.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43419.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5532.89, "90th_percentile": 5532.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5532.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17852.1, "90th_percentile": 21635.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18974.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38284.95, "90th_percentile": 161961.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43865.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "418", "type": "MS-DRG" } ], "description": "Laparoscopic Cholecystectomy Without C.D.E. With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 36704.26, "minimum": 14347.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36704.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32808.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34249.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30856.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28947.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14347.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30660.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15637.3, "90th_percentile": 79103.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36667.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11736.92, "90th_percentile": 13960.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13300.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 12175.73, "90th_percentile": 12175.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12175.73, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9492.01, "90th_percentile": 9492.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9492.01, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29905.71, "90th_percentile": 34580.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 32574.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9082.87, "90th_percentile": 9082.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9082.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11711.74, "90th_percentile": 13495.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13400.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 31170.85, "90th_percentile": 31170.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31170.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7773.63, "90th_percentile": 9506.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7773.63, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6795.6, "90th_percentile": 8591.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 7267.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11905.0, "90th_percentile": 11905.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11905.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 78626.76, "90th_percentile": 78626.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78626.76, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 48129.01, "90th_percentile": 69741.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48129.01, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 150.0, "90th_percentile": 150.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 150.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7507.52, "90th_percentile": 7507.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7507.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12044.34, "90th_percentile": 13740.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 13267.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32367.23, "90th_percentile": 32799.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32536.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 33173.56, "90th_percentile": 33173.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33173.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 11682.35, "90th_percentile": 13424.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12239.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3701.34, "90th_percentile": 3701.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3701.34, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12314.17, "90th_percentile": 12314.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12314.17, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28045.55, "90th_percentile": 31483.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28945.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9001.05, "90th_percentile": 9087.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9001.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1471.31, "90th_percentile": 13524.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13302.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28945.71, "90th_percentile": 31223.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30610.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "419", "type": "MS-DRG" } ], "description": "Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29159.81, "minimum": 11817.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29159.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26064.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27209.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24513.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22997.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11817.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24358.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29132.14, "90th_percentile": 29132.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29132.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10904.77, "90th_percentile": 10904.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10904.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31933.77, "90th_percentile": 31933.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31933.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7507.52, "90th_percentile": 7507.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7507.52, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24369.06, "90th_percentile": 26064.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 25880.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3541.8, "90th_percentile": 3541.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3541.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10841.07, "90th_percentile": 10841.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10841.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5766.39, "90th_percentile": 5766.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5766.39, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26023.25, "90th_percentile": 26023.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26023.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6795.6, "90th_percentile": 8591.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6795.6, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 97808.98, "90th_percentile": 97808.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 97808.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9492.01, "90th_percentile": 9492.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9492.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9915.76, "90th_percentile": 11611.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10869.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24513.95, "90th_percentile": 25849.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24663.01, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 1087.08, "90th_percentile": 1087.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1087.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7507.52, "90th_percentile": 9492.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7598.19, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 56580.13, "90th_percentile": 56580.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56580.13, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22997.39, "90th_percentile": 25119.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23859.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7119.2, "90th_percentile": 7119.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7119.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18086.41, "90th_percentile": 24320.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 22597.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "420", "type": "MS-DRG" } ], "description": "Hepatobiliary Diagnostic Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 78104.73, "minimum": 27669.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78104.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69814.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 72881.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65660.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61598.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27669.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65244.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25345.3, "90th_percentile": 27537.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25862.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69820.57, "90th_percentile": 69820.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69820.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 37460.77, "90th_percentile": 37460.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37460.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26467.31, "90th_percentile": 26467.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26467.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15181.09, "90th_percentile": 15181.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15181.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 76374.47, "90th_percentile": 76374.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76374.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 77481.76, "90th_percentile": 77481.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77481.76, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27074.64, "90th_percentile": 27074.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27074.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 27503.9, "90th_percentile": 27503.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27503.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 15989.97, "90th_percentile": 15989.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15989.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25837.68, "90th_percentile": 26321.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25900.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 64842.14, "90th_percentile": 64842.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64842.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "421", "type": "MS-DRG" } ], "description": "Hepatobiliary Diagnostic Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 36239.51, "minimum": 14703.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36239.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32393.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33816.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30465.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28580.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14703.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30272.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10995.66, "90th_percentile": 10995.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10995.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11555.85, "90th_percentile": 11555.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11555.85, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 33877.97, "90th_percentile": 33877.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33877.97, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13471.37, "90th_percentile": 13471.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13471.37, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11555.85, "90th_percentile": 11555.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11555.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28273.45, "90th_percentile": 28273.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28273.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13351.39, "90th_percentile": 13362.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13351.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "422", "type": "MS-DRG" } ], "description": "Hepatobiliary Diagnostic Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32517.08, "minimum": 12078.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32517.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29065.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30342.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27336.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25645.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12078.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27162.95 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11962.77, "90th_percentile": 11962.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11962.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11454.88, "90th_percentile": 11454.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11454.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4914.76, "90th_percentile": 4914.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4914.76, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11840.9, "90th_percentile": 11840.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11840.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "423", "type": "MS-DRG" } ], "description": "Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 90008.99, "minimum": 33462.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90008.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 80455.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 83989.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75668.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70987.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33462.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75188.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3567.37, "90th_percentile": 3567.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3567.37, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31541.36, "90th_percentile": 31555.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31555.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 16193.16, "90th_percentile": 16193.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16193.16, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6195.09, "90th_percentile": 6195.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6195.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 106977.52, "90th_percentile": 106977.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 106977.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31587.19, "90th_percentile": 31587.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31587.19, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 29477.12, "90th_percentile": 29477.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29477.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 75584.32, "90th_percentile": 75584.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75584.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30418.83, "90th_percentile": 31828.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30418.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 86159.4, "90th_percentile": 86159.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 86159.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "424", "type": "MS-DRG" } ], "description": "Other Hepatobiliary Or Pancreas O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 50527.29, "minimum": 18201.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50527.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45164.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47148.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42477.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39849.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18201.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42207.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 53910.86, "90th_percentile": 53910.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53910.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18106.06, "90th_percentile": 18106.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18106.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44848.58, "90th_percentile": 44848.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44848.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 45552.59, "90th_percentile": 45552.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45552.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8551.16, "90th_percentile": 8551.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8551.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18265.13, "90th_percentile": 18265.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18265.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41577.87, "90th_percentile": 41577.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41577.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "425", "type": "MS-DRG" } ], "description": "Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34207.89, "minimum": 12861.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34207.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30577.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31920.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28757.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26978.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12861.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28575.36 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "426", "type": "MS-DRG" } ], "description": "Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made", "standard_charges": [ { "billing_class": "facility", "maximum": 231968.29, "minimum": 86799.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 231968.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 207347.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 216455.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 195010.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 182945.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86799.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 193773.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 130101.02, "90th_percentile": 204597.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 130101.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "10th_percentile": 7716.41, "90th_percentile": 7716.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7716.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69618.5, "90th_percentile": 80420.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 79829.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39699.53, "90th_percentile": 39699.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39699.53, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 156310.1, "90th_percentile": 156310.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 156310.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69710.91, "90th_percentile": 85114.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71265.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 32512.54, "90th_percentile": 32512.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32512.54, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 39810.38, "90th_percentile": 50720.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39892.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 231376.05, "90th_percentile": 231376.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 231376.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 79286.02, "90th_percentile": 79286.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79286.02, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 56033.57, "90th_percentile": 56033.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56033.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 78088.12, "90th_percentile": 83140.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 79295.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 343275.73, "90th_percentile": 343275.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 343275.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 79868.62, "90th_percentile": 83110.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79868.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40686.56, "90th_percentile": 40686.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40686.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 228430.42, "90th_percentile": 228430.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 228430.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 30863.38, "90th_percentile": 30863.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30863.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 78733.51, "90th_percentile": 85092.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79235.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 230891.01, "90th_percentile": 230891.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 230891.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "427", "type": "MS-DRG" } ], "description": "Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 157101.33, "minimum": 57268.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 157101.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 140426.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 146595.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132071.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 123900.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57268.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 131233.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 101112.13, "90th_percentile": 238880.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 146500.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48562.8, "90th_percentile": 55049.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 53973.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 178222.61, "90th_percentile": 178222.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 178222.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 55283.37, "90th_percentile": 56976.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55427.39, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32546.84, "90th_percentile": 32546.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32546.84, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 122777.81, "90th_percentile": 257866.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 140505.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 27729.59, "90th_percentile": 27729.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27729.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50346.04, "90th_percentile": 54626.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 53231.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 48230.4, "90th_percentile": 68573.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67765.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 26654.74, "90th_percentile": 26654.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26654.74, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 26230.69, "90th_percentile": 39810.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 29460.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 80839.76, "90th_percentile": 80839.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80839.76, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 108467.52, "90th_percentile": 108467.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108467.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 126785.86, "90th_percentile": 162043.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 136595.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 54418.01, "90th_percentile": 54418.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54418.01, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48845.98, "90th_percentile": 54456.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 54377.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 130404.69, "90th_percentile": 215448.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 167574.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 67382.39, "90th_percentile": 67382.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67382.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 53963.47, "90th_percentile": 56135.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54446.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28978.67, "90th_percentile": 32546.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28978.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16490.44, "90th_percentile": 171547.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 156460.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 27479.77, "90th_percentile": 41706.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30863.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 53029.58, "90th_percentile": 55248.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 54820.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 155755.61, "90th_percentile": 230184.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 173583.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "428", "type": "MS-DRG" } ], "description": "Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 121835.58, "minimum": 44870.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 121835.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 108903.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 113687.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102424.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 96087.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44870.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101774.63 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 108262.05, "90th_percentile": 108262.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108262.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43597.79, "90th_percentile": 43597.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43597.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 107925.51, "90th_percentile": 242757.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108882.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43384.86, "90th_percentile": 43384.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43384.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 45564.65, "90th_percentile": 45564.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45564.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 29460.5, "90th_percentile": 29460.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29460.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 132622.43, "90th_percentile": 132622.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 132622.43, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43591.79, "90th_percentile": 79346.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43591.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 135501.8, "90th_percentile": 135501.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 135501.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 41088.84, "90th_percentile": 42910.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41088.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 44972.01, "90th_percentile": 44972.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44972.01, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 250603.93, "90th_percentile": 250603.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 250603.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 25878.6, "90th_percentile": 25878.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25878.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43908.97, "90th_percentile": 43908.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43908.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "429", "type": "MS-DRG" } ], "description": "Combined Anterior And Posterior Cervical Spinal Fusion With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 184572.54, "minimum": 71177.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 184572.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 164981.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 172229.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 155165.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 145566.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71177.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 154181.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 163826.07, "90th_percentile": 163826.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 163826.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63080.02, "90th_percentile": 63080.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63080.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61822.24, "90th_percentile": 61822.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61822.24, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 44440.53, "90th_percentile": 44440.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44440.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6445.39, "90th_percentile": 6445.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6445.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 169172.98, "90th_percentile": 169172.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 169172.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "534", "type": "MS-DRG" } ], "description": "Fractures Of Femur Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18012.42, "minimum": 7470.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18012.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16100.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16807.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15142.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14205.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7470.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15046.57 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "535", "type": "MS-DRG" } ], "description": "Fractures Of Hip And Pelvis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29432.02, "minimum": 11166.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29432.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26308.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27463.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24742.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23212.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11166.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24585.86 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9971.13, "90th_percentile": 9971.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9971.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10910.11, "90th_percentile": 10910.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10910.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10928.99, "90th_percentile": 10965.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10928.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11009.79, "90th_percentile": 11009.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11009.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "536", "type": "MS-DRG" } ], "description": "Fractures Of Hip And Pelvis Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17946.03, "minimum": 7482.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17946.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16041.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16745.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15086.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14153.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7482.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14991.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5853.24, "90th_percentile": 5853.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5853.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4534.45, "90th_percentile": 4534.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4534.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5156.55, "90th_percentile": 5156.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5156.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7031.22, "90th_percentile": 7031.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7031.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 574.79, "90th_percentile": 574.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 574.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7018.04, "90th_percentile": 7018.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7018.04, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7084.24, "90th_percentile": 7084.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7084.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "537", "type": "MS-DRG" } ], "description": "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20336.18, "minimum": 8621.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20336.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18177.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18976.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17096.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16038.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8621.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16987.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7829.98, "90th_percentile": 7829.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7829.98, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6638.3, "90th_percentile": 6638.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6638.3, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7904.28, "90th_percentile": 7904.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7904.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "538", "type": "MS-DRG" } ], "description": "Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14860.97, "minimum": 6804.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14860.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13283.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13867.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12493.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11720.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6804.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12414.02 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 515.29, "90th_percentile": 515.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 515.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "539", "type": "MS-DRG" } ], "description": "Osteomyelitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 44764.37, "minimum": 16506.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44764.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40013.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41770.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37632.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35304.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16506.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37393.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13160.03, "90th_percentile": 13160.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13160.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13103.53, "90th_percentile": 13103.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13103.53, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40440.18, "90th_percentile": 40440.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40440.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9344.18, "90th_percentile": 9344.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9344.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15555.64, "90th_percentile": 16188.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16159.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 6487.57, "90th_percentile": 6487.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6487.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8757.02, "90th_percentile": 8757.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8757.02, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14537.7, "90th_percentile": 16132.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15418.28, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39677.47, "90th_percentile": 39677.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39677.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 16155.16, "90th_percentile": 16155.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16155.16, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13194.2, "90th_percentile": 13194.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13194.2, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 12511.74, "90th_percentile": 12511.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12511.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13192.01, "90th_percentile": 13192.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13192.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37329.46, "90th_percentile": 37329.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37329.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "540", "type": "MS-DRG" } ], "description": "Osteomyelitis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 28646.37, "minimum": 11277.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28646.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25605.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26730.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24082.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22592.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23929.57 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10640.32, "90th_percentile": 10640.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10640.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14635.45, "90th_percentile": 14635.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14635.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9257.42, "90th_percentile": 9257.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9257.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6016.66, "90th_percentile": 6016.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6016.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9191.76, "90th_percentile": 9191.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9191.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7167.22, "90th_percentile": 7167.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7167.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9820.07, "90th_percentile": 10738.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9820.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "541", "type": "MS-DRG" } ], "description": "Osteomyelitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19360.2, "minimum": 7325.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19360.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17305.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18065.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16275.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15268.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7325.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16172.43 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5486.44, "90th_percentile": 5486.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5486.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "542", "type": "MS-DRG" } ], "description": "Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41272.1, "minimum": 14928.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41272.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36891.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38512.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34696.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32549.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14928.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34476.41 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 32932.47, "90th_percentile": 32932.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32932.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7108.01, "90th_percentile": 14946.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 13076.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38891.07, "90th_percentile": 38891.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38891.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8383.85, "90th_percentile": 14963.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 13624.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 14599.71, "90th_percentile": 14599.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14599.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7259.86, "90th_percentile": 7259.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7259.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 85019.86, "90th_percentile": 85019.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85019.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10837.8, "90th_percentile": 14990.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 12879.98, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36591.4, "90th_percentile": 36591.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36591.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13857.21, "90th_percentile": 13857.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13857.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 9066.36, "90th_percentile": 15048.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9066.36, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15484.83, "90th_percentile": 15484.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15484.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7501.27, "90th_percentile": 15125.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 14560.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32553.46, "90th_percentile": 32553.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32553.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "543", "type": "MS-DRG" } ], "description": "Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23476.56, "minimum": 9193.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23476.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20984.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21906.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19736.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18515.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9193.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19611.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 23476.56, "90th_percentile": 23476.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23476.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4902.62, "90th_percentile": 8890.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 8159.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20838.2, "90th_percentile": 21178.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20986.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7287.34, "90th_percentile": 9013.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 8881.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5086.94, "90th_percentile": 5086.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5086.94, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7259.86, "90th_percentile": 7259.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7259.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 6145.52, "90th_percentile": 6145.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6145.52, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8020.41, "90th_percentile": 8020.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8020.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5596.8, "90th_percentile": 8925.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 7836.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20784.05, "90th_percentile": 20784.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20784.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7142.15, "90th_percentile": 7142.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7142.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8892.91, "90th_percentile": 10118.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8910.49, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6951.15, "90th_percentile": 7631.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6951.15, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 874.09, "90th_percentile": 9044.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 7332.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18974.82, "90th_percentile": 18974.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18974.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "544", "type": "MS-DRG" } ], "description": "Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16724.4, "minimum": 7070.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16724.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14949.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15605.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14059.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13189.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7070.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13970.63 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6595.6, "90th_percentile": 6595.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6595.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15757.86, "90th_percentile": 15757.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15757.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6607.02, "90th_percentile": 6607.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6607.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5744.43, "90th_percentile": 6625.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6052.86, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 6604.56, "90th_percentile": 6604.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6604.56, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4189.71, "90th_percentile": 6657.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4189.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "545", "type": "MS-DRG" } ], "description": "Connective Tissue Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 55918.4, "minimum": 20483.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55918.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49983.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 52178.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47009.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44101.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20483.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46711.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 32908.4, "90th_percentile": 32908.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32908.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13763.57, "90th_percentile": 19957.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18012.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28605.66, "90th_percentile": 28605.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28605.66, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48254.92, "90th_percentile": 48254.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48254.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18137.8, "90th_percentile": 19937.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18137.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 11964.0, "90th_percentile": 11964.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11964.0, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8474.92, "90th_percentile": 8474.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8474.92, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20119.09, "90th_percentile": 20119.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20119.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 14608.67, "90th_percentile": 14608.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14608.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14970.43, "90th_percentile": 19928.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19928.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 19313.86, "90th_percentile": 19648.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19313.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8706.39, "90th_percentile": 8706.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8706.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25318.03, "90th_percentile": 25318.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25318.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12240.98, "90th_percentile": 20182.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12951.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46641.52, "90th_percentile": 46641.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46641.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "546", "type": "MS-DRG" } ], "description": "Connective Tissue Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 25621.06, "minimum": 10167.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25621.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22901.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23907.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21539.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20206.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10167.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21402.4 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 193720.41, "90th_percentile": 193720.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 193720.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8806.64, "90th_percentile": 8806.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8806.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 332595.5, "90th_percentile": 332595.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 332595.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 17365.52, "90th_percentile": 17365.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17365.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6946.53, "90th_percentile": 6946.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6946.53, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 35154.48, "90th_percentile": 35154.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35154.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8361.95, "90th_percentile": 9649.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9611.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20206.5, "90th_percentile": 20206.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20206.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "547", "type": "MS-DRG" } ], "description": "Connective Tissue Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16514.15, "minimum": 7704.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16514.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14761.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15409.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13883.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13024.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7704.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13795.0 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 598.21, "90th_percentile": 598.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 598.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14656.86, "90th_percentile": 479304.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14656.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6864.46, "90th_percentile": 6864.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6864.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 16218.66, "90th_percentile": 16218.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16218.66, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15828.66, "90th_percentile": 15828.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15828.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "548", "type": "MS-DRG" } ], "description": "Septic Arthritis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 44582.9, "minimum": 16205.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44582.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39850.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41601.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37479.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35161.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16205.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37242.06 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16188.41, "90th_percentile": 16188.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16188.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14416.54, "90th_percentile": 14416.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14416.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "549", "type": "MS-DRG" } ], "description": "Septic Arthritis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 26667.86, "minimum": 10585.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26667.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23837.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24884.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22419.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21032.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10585.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22276.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2875.07, "90th_percentile": 2875.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2875.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8586.0, "90th_percentile": 8586.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8586.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "550", "type": "MS-DRG" } ], "description": "Septic Arthritis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19079.14, "minimum": 7998.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19079.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17054.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17803.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16039.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15047.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7998.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15937.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "551", "type": "MS-DRG" } ], "description": "Medical Back Problems With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 37762.13, "minimum": 14226.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37762.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33754.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35236.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31745.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29781.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14226.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31544.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15803.37, "90th_percentile": 15803.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15803.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11520.24, "90th_percentile": 14673.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12549.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17635.75, "90th_percentile": 17635.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17635.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35581.85, "90th_percentile": 35581.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35581.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8806.15, "90th_percentile": 13947.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11829.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 11511.13, "90th_percentile": 11511.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11511.13, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4763.98, "90th_percentile": 7116.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5391.72, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 35182.27, "90th_percentile": 35182.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35182.27, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 3856.11, "90th_percentile": 3856.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3856.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11608.26, "90th_percentile": 13947.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 12562.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 22412.37, "90th_percentile": 22412.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22412.37, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6047.23, "90th_percentile": 6047.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6047.23, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12682.87, "90th_percentile": 12990.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12980.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11845.97, "90th_percentile": 14075.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12354.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29298.8, "90th_percentile": 30894.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29298.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "552", "type": "MS-DRG" } ], "description": "Medical Back Problems Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21329.86, "minimum": 8675.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21329.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19065.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19903.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17931.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16822.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8675.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17817.77 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 12664.85, "90th_percentile": 21309.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 15997.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 687.71, "90th_percentile": 8162.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 7017.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 4406.81, "90th_percentile": 4406.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4406.81, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5956.57, "90th_percentile": 5956.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5956.57, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15444.77, "90th_percentile": 20045.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 18507.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5699.82, "90th_percentile": 5699.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5699.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6617.01, "90th_percentile": 8427.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 7475.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 10283.41, "90th_percentile": 10283.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10283.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5751.17, "90th_percentile": 6512.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5751.17, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4413.09, "90th_percentile": 5391.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 4683.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6578.02, "90th_percentile": 6578.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6578.02, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22512.19, "90th_percentile": 52112.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22512.19, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 3305.0, "90th_percentile": 3305.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3305.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8160.37, "90th_percentile": 12156.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8585.37, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5174.55, "90th_percentile": 5956.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5174.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5954.36, "90th_percentile": 8167.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 6658.84, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14075.8, "90th_percentile": 18908.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18859.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 2865.23, "90th_percentile": 6299.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2865.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7524.33, "90th_percentile": 7901.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7524.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 687.71, "90th_percentile": 687.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 687.71, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5174.55, "90th_percentile": 5956.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5956.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6805.29, "90th_percentile": 8502.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8447.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16822.17, "90th_percentile": 17817.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17743.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4906.9, "90th_percentile": 5648.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4906.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 944.34, "90th_percentile": 8238.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 7025.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11389.66, "90th_percentile": 19045.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16510.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "553", "type": "MS-DRG" } ], "description": "Bone Diseases And Arthropathies With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28909.73, "minimum": 11277.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28909.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25841.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26976.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24303.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22800.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11277.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24149.57 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10759.7, "90th_percentile": 10759.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10759.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10767.09, "90th_percentile": 10767.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10767.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10729.89, "90th_percentile": 10729.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10729.89, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21616.83, "90th_percentile": 21616.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21616.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "554", "type": "MS-DRG" } ], "description": "Bone Diseases And Arthropathies Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18470.53, "minimum": 7657.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18470.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16510.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17235.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15527.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14567.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7657.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15429.25 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5462.14, "90th_percentile": 7234.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5814.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6685.04, "90th_percentile": 7252.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6685.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7577.18, "90th_percentile": 7577.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7577.18, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6721.06, "90th_percentile": 7235.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7174.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7437.5, "90th_percentile": 7437.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7437.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14567.11, "90th_percentile": 15405.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14567.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "555", "type": "MS-DRG" } ], "description": "Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29799.39, "minimum": 11475.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29799.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26636.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27806.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25051.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23501.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11475.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24892.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10093.34, "90th_percentile": 10093.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10093.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16883.34, "90th_percentile": 16883.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16883.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11036.18, "90th_percentile": 11036.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11036.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8640.2, "90th_percentile": 8640.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8640.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4546.13, "90th_percentile": 4546.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4546.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11066.99, "90th_percentile": 11066.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11066.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8722.57, "90th_percentile": 8722.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8722.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9176.88, "90th_percentile": 9176.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9176.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "556", "type": "MS-DRG" } ], "description": "Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18069.96, "minimum": 7660.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18069.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16152.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16861.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15190.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14251.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7660.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15094.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18052.82, "90th_percentile": 18052.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18052.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6459.17, "90th_percentile": 7072.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6478.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18052.81, "90th_percentile": 18052.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18052.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9198.35, "90th_percentile": 9198.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9198.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16037.69, "90th_percentile": 17272.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16037.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6124.11, "90th_percentile": 6908.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6124.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4571.4, "90th_percentile": 4571.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4571.4, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4546.13, "90th_percentile": 4546.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4546.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 10044.78, "90th_percentile": 10044.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10044.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6478.78, "90th_percentile": 7441.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7051.75, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5654.15, "90th_percentile": 5654.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5654.15, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4466.09, "90th_percentile": 4466.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4466.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14251.19, "90th_percentile": 14251.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14251.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "557", "type": "MS-DRG" } ], "description": "Tendonitis, Myositis And Bursitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34296.41, "minimum": 12757.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34296.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30656.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32002.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28832.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27048.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12757.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28649.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12567.96, "90th_percentile": 12591.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12567.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10406.41, "90th_percentile": 11461.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10406.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10366.14, "90th_percentile": 11770.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10366.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9198.35, "90th_percentile": 9198.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9198.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1242.04, "90th_percentile": 1242.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1242.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "558", "type": "MS-DRG" } ], "description": "Tendonitis, Myositis And Bursitis Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19116.76, "minimum": 8147.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19116.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17087.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17838.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16071.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15076.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8147.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15969.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17715.4, "90th_percentile": 17715.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17715.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5087.65, "90th_percentile": 6507.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5087.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6483.65, "90th_percentile": 6483.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6483.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4571.4, "90th_percentile": 4571.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4571.4, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5052.6, "90th_percentile": 6487.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5052.6, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5581.92, "90th_percentile": 5581.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5581.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6442.59, "90th_percentile": 6442.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6442.59, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5581.92, "90th_percentile": 5581.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5581.92, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5171.72, "90th_percentile": 5171.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5171.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14610.37, "90th_percentile": 15076.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14610.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "559", "type": "MS-DRG" } ], "description": "Aftercare, Musculoskeletal System And Connective Tissue With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41077.35, "minimum": 15693.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41077.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36717.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38330.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34532.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32396.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15693.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34313.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8755.84, "90th_percentile": 14891.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8755.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13390.45, "90th_percentile": 13390.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13390.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13910.82, "90th_percentile": 13910.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13910.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14880.04, "90th_percentile": 14880.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14880.04, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34422.32, "90th_percentile": 34422.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34422.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 3490.01, "90th_percentile": 3490.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3490.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "560", "type": "MS-DRG" } ], "description": "Aftercare, Musculoskeletal System And Connective Tissue With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 25202.78, "minimum": 9955.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25202.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22527.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23517.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21187.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19876.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9955.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21053.0 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 654.43, "90th_percentile": 654.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 654.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5251.66, "90th_percentile": 9803.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5251.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5762.68, "90th_percentile": 5762.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5762.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "561", "type": "MS-DRG" } ], "description": "Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18094.31, "minimum": 7453.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18094.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16173.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16884.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15211.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14270.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7453.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15114.97 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5291.91, "90th_percentile": 5291.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5291.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9757.4, "90th_percentile": 9757.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9757.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "562", "type": "MS-DRG" } ], "description": "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32393.14, "minimum": 12275.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32393.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28954.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30226.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27232.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25547.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12275.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27059.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30642.8, "90th_percentile": 30642.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30642.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1037.37, "90th_percentile": 1037.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1037.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7461.89, "90th_percentile": 7461.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7461.89, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7819.05, "90th_percentile": 7819.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7819.05, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10458.96, "90th_percentile": 10458.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10458.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10786.57, "90th_percentile": 10786.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10786.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12026.6, "90th_percentile": 12026.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12026.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "563", "type": "MS-DRG" } ], "description": "Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19778.47, "minimum": 8164.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19778.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17679.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18455.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16627.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15598.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8164.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16521.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6993.56, "90th_percentile": 6993.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6993.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5268.62, "90th_percentile": 5268.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5268.62, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15145.07, "90th_percentile": 15145.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15145.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6288.48, "90th_percentile": 7943.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6695.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4769.01, "90th_percentile": 4769.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4769.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5465.22, "90th_percentile": 5913.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5717.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14999.6, "90th_percentile": 14999.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14999.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7728.38, "90th_percentile": 7728.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7728.38, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5780.1, "90th_percentile": 7725.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5780.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16497.76, "90th_percentile": 16497.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16497.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "564", "type": "MS-DRG" } ], "description": "Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34727.97, "minimum": 13197.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34727.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31041.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32405.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29194.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27388.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13197.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29009.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11303.25, "90th_percentile": 14510.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11546.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12758.23, "90th_percentile": 12758.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12758.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 99382.72, "90th_percentile": 99382.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99382.72, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 19343.86, "90th_percentile": 19343.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19343.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11805.35, "90th_percentile": 12939.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12718.33, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 1104.28, "90th_percentile": 1104.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1104.28, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11516.78, "90th_percentile": 11705.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11516.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "565", "type": "MS-DRG" } ], "description": "Other Musculoskeletal System And Connective Tissue Diagnoses With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22564.77, "minimum": 8777.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22564.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20169.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21055.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18969.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17796.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8777.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18849.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5954.29, "90th_percentile": 7866.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7842.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20318.19, "90th_percentile": 20318.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20318.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8606.36, "90th_percentile": 8606.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8606.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 2332.32, "90th_percentile": 2332.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2332.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13512.52, "90th_percentile": 13512.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13512.52, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8616.42, "90th_percentile": 8616.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8616.42, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8578.64, "90th_percentile": 8578.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8578.64, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6457.06, "90th_percentile": 6457.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6457.06, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7196.92, "90th_percentile": 7196.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7196.92, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9035.11, "90th_percentile": 9035.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9035.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17464.86, "90th_percentile": 17464.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17464.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "566", "type": "MS-DRG" } ], "description": "Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16553.99, "minimum": 7029.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16553.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14796.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15446.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13916.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13055.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7029.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13828.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3757.0, "90th_percentile": 3757.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3757.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29473.81, "90th_percentile": 29473.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29473.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4302.67, "90th_percentile": 4302.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4302.67, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6522.41, "90th_percentile": 6522.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6522.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13057.34, "90th_percentile": 13057.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13057.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2466.0, "90th_percentile": 2466.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2466.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "533", "type": "MS-DRG" } ], "description": "Fractures Of Femur With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33745.35, "minimum": 13385.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33745.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30163.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31488.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28368.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26613.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13385.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28188.98 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "522", "type": "MS-DRG" } ], "description": "Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 46656.57, "minimum": 17656.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46656.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41704.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43536.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39223.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36796.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17656.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38974.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 60542.76, "90th_percentile": 60542.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60542.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15011.82, "90th_percentile": 16817.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 15299.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 15576.81, "90th_percentile": 15576.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15576.81, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41702.43, "90th_percentile": 41702.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41702.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15126.07, "90th_percentile": 17186.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 15800.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14261.47, "90th_percentile": 14261.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14261.47, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14803.69, "90th_percentile": 16814.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 15699.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15241.3, "90th_percentile": 16792.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15395.61, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 17880.35, "90th_percentile": 17880.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17880.35, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13558.35, "90th_percentile": 13558.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13558.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15838.74, "90th_percentile": 15838.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15838.74, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 60967.89, "90th_percentile": 60967.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60967.89, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15437.6, "90th_percentile": 17308.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17046.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "521", "type": "MS-DRG" } ], "description": "Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 64503.01, "minimum": 23500.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64503.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57656.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 60189.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54226.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50871.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23500.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53882.21 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 63426.25, "90th_percentile": 63426.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63426.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19828.63, "90th_percentile": 22842.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 20811.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 57250.54, "90th_percentile": 57250.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57250.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20858.51, "90th_percentile": 23019.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22829.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 21146.76, "90th_percentile": 21146.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21146.76, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18635.19, "90th_percentile": 23039.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20796.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 20976.55, "90th_percentile": 20976.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20976.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 20749.6, "90th_percentile": 20749.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20749.6, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21036.57, "90th_percentile": 41111.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23087.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "520", "type": "MS-DRG" } ], "description": "Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31715.94, "minimum": 12811.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31715.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28349.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29594.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26662.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25013.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12811.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26493.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 25672.18, "90th_percentile": 37687.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31313.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11695.85, "90th_percentile": 12488.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11700.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24605.94, "90th_percentile": 28351.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27354.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8296.21, "90th_percentile": 8296.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8296.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11282.91, "90th_percentile": 11282.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11282.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 36914.58, "90th_percentile": 36914.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36914.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6691.66, "90th_percentile": 6691.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6691.66, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7929.83, "90th_percentile": 8271.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7929.83, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 49137.08, "90th_percentile": 49137.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49137.08, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 27190.18, "90th_percentile": 27190.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27190.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8669.91, "90th_percentile": 8669.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8669.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11744.53, "90th_percentile": 11744.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11744.53, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24861.16, "90th_percentile": 62008.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24861.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8669.91, "90th_percentile": 8669.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8669.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25975.3, "90th_percentile": 25975.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25975.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8221.47, "90th_percentile": 8221.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8221.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10521.78, "90th_percentile": 10521.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10521.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25291.91, "90th_percentile": 27574.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26314.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "519", "type": "MS-DRG" } ], "description": "Back And Neck Procedures Except Spinal Fusion With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 43635.69, "minimum": 16743.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43635.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39004.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40717.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36683.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34414.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16743.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36450.82 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 43364.69, "90th_percentile": 45852.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43640.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1397.74, "90th_percentile": 16988.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14366.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 47782.95, "90th_percentile": 47782.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47782.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38232.06, "90th_percentile": 38732.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38232.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15751.85, "90th_percentile": 16152.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15767.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37267.12, "90th_percentile": 37267.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37267.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 21913.2, "90th_percentile": 21913.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21913.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 11089.75, "90th_percentile": 11089.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11089.75, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7847.76, "90th_percentile": 13401.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12257.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 61807.41, "90th_percentile": 61807.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61807.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 122643.31, "90th_percentile": 122643.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 122643.31, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8669.91, "90th_percentile": 8669.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8669.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13603.69, "90th_percentile": 15763.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 14820.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44392.65, "90th_percentile": 44392.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44392.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15105.04, "90th_percentile": 15105.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15105.04, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35377.77, "90th_percentile": 42106.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36764.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14048.04, "90th_percentile": 16436.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14944.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34319.07, "90th_percentile": 34319.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34319.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "518", "type": "MS-DRG" } ], "description": "Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator", "standard_charges": [ { "billing_class": "facility", "maximum": 79313.08, "minimum": 30233.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79313.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70894.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 74009.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66676.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62551.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30233.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66253.71 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 79242.24, "90th_percentile": 79242.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79242.24, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26892.49, "90th_percentile": 29337.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26892.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 70396.93, "90th_percentile": 70396.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 70396.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25187.74, "90th_percentile": 58270.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28103.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15044.11, "90th_percentile": 15044.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15044.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24434.34, "90th_percentile": 27909.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25768.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 69222.04, "90th_percentile": 69222.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69222.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27470.45, "90th_percentile": 27470.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27470.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 152789.09, "90th_percentile": 152789.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 152789.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "517", "type": "MS-DRG" } ], "description": "Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33032.73, "minimum": 13144.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33032.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29526.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30823.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27769.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26051.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13144.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27593.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11081.55, "90th_percentile": 12168.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11084.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10966.1, "90th_percentile": 12218.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11888.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 30212.19, "90th_percentile": 30212.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30212.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12257.09, "90th_percentile": 14169.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12257.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 83325.54, "90th_percentile": 83325.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83325.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11268.0, "90th_percentile": 12159.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11443.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32005.54, "90th_percentile": 40166.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33809.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 19279.41, "90th_percentile": 19279.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19279.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11382.22, "90th_percentile": 11382.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11382.22, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23565.13, "90th_percentile": 23565.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23565.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8307.44, "90th_percentile": 8307.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8307.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12243.52, "90th_percentile": 12264.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12248.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28364.41, "90th_percentile": 31056.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31056.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "516", "type": "MS-DRG" } ], "description": "Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 44518.72, "minimum": 17348.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44518.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39793.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41541.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37425.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35110.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17348.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37188.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 54149.67, "90th_percentile": 54149.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54149.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14366.28, "90th_percentile": 16646.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 14967.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39513.81, "90th_percentile": 39513.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39513.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 11226.83, "90th_percentile": 11226.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11226.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14234.82, "90th_percentile": 16466.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 15664.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 40118.6, "90th_percentile": 40118.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40118.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 13074.23, "90th_percentile": 13074.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13074.23, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10619.97, "90th_percentile": 13318.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13318.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 121097.21, "90th_percentile": 121097.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121097.21, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13284.36, "90th_percentile": 16084.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 14995.33, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42388.84, "90th_percentile": 42388.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42388.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 16076.19, "90th_percentile": 16076.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16076.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 16134.01, "90th_percentile": 16134.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16134.01, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15838.96, "90th_percentile": 15838.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15838.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14984.16, "90th_percentile": 14994.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14984.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12677.48, "90th_percentile": 16307.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15900.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35112.21, "90th_percentile": 37739.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35112.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "515", "type": "MS-DRG" } ], "description": "Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 68433.48, "minimum": 25959.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68433.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 61169.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 63857.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57530.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53971.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25959.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57165.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 73640.06, "90th_percentile": 73640.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73640.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19780.95, "90th_percentile": 24409.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22017.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42656.63, "90th_percentile": 42656.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42656.63, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60740.92, "90th_percentile": 265707.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61173.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 14079.18, "90th_percentile": 14079.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14079.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22820.96, "90th_percentile": 24299.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24202.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 24640.65, "90th_percentile": 24640.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24640.65, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16017.77, "90th_percentile": 121963.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24069.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 61041.01, "90th_percentile": 61041.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61041.01, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40461.91, "90th_percentile": 40461.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40461.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 434657.24, "90th_percentile": 434657.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 434657.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2439.88, "90th_percentile": 24419.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22388.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "514", "type": "MS-DRG" } ], "description": "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22564.77, "minimum": 9149.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22564.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20169.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21055.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18969.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17796.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9149.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18849.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22564.77, "90th_percentile": 22564.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22564.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7850.27, "90th_percentile": 7850.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7850.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17796.1, "90th_percentile": 17796.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17796.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8663.48, "90th_percentile": 8663.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8663.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "513", "type": "MS-DRG" } ], "description": "Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33318.22, "minimum": 13436.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33318.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29781.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31090.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28009.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26277.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13436.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27832.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29219.53, "90th_percentile": 29219.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29219.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28970.86, "90th_percentile": 28970.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28970.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12277.4, "90th_percentile": 12277.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12277.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6098.73, "90th_percentile": 6098.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6098.73, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10207.94, "90th_percentile": 10207.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10207.94, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13052.44, "90th_percentile": 13052.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13052.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 181197.83, "90th_percentile": 181197.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 181197.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "512", "type": "MS-DRG" } ], "description": "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35580.01, "minimum": 14066.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35580.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31803.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33200.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29911.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28060.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14066.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29721.55 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "511", "type": "MS-DRG" } ], "description": "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 43407.74, "minimum": 17358.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43407.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38800.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40504.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36491.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34234.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17358.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36260.4 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3392.22, "90th_percentile": 3392.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3392.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15175.09, "90th_percentile": 15671.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15414.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11821.57, "90th_percentile": 11821.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11821.57, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16875.74, "90th_percentile": 16875.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16875.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36199.83, "90th_percentile": 38342.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36199.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "510", "type": "MS-DRG" } ], "description": "Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 63250.4, "minimum": 24667.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63250.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 56536.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 59020.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53173.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49883.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24667.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52835.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20424.52, "90th_percentile": 20424.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20424.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14667.23, "90th_percentile": 14667.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14667.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "509", "type": "MS-DRG" } ], "description": "Arthroscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 38873.1, "minimum": 30657.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38873.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34747.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36273.48 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32679.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30657.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32472.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "508", "type": "MS-DRG" } ], "description": "Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28562.27, "minimum": 12971.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28562.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25530.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26652.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24011.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22526.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12971.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23859.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "507", "type": "MS-DRG" } ], "description": "Major Shoulder Or Elbow Joint Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 42892.09, "minimum": 15238.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42892.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38339.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40023.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36058.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33827.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15238.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35829.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15534.66, "90th_percentile": 15534.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15534.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16086.14, "90th_percentile": 16086.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16086.14, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "506", "type": "MS-DRG" } ], "description": "Major Thumb Or Joint Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 33174.37, "minimum": 11688.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33174.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29653.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30955.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27888.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26163.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11688.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27712.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "505", "type": "MS-DRG" } ], "description": "Foot Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38853.18, "minimum": 15133.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38853.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34729.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36254.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32662.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30642.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15133.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32455.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12882.76, "90th_percentile": 12882.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12882.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2880.07, "90th_percentile": 2880.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2880.07, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "504", "type": "MS-DRG" } ], "description": "Foot Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 38853.18, "minimum": 15726.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38853.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34729.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36254.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32662.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30642.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15726.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32455.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14128.24, "90th_percentile": 14128.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14128.24, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 515052.68, "90th_percentile": 515052.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 515052.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8723.15, "90th_percentile": 10648.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8788.74, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13436.89, "90th_percentile": 13436.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13436.89, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13076.3, "90th_percentile": 13076.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13076.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13036.95, "90th_percentile": 13036.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13036.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12333.79, "90th_percentile": 12333.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12333.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "503", "type": "MS-DRG" } ], "description": "Foot Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 58569.69, "minimum": 22885.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58569.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52353.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 54652.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49238.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46192.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48925.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20840.19, "90th_percentile": 20840.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20840.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 17908.41, "90th_percentile": 17908.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17908.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44526.57, "90th_percentile": 44526.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44526.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "502", "type": "MS-DRG" } ], "description": "Soft Tissue Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 30919.22, "minimum": 11662.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30919.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27637.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28851.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25993.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24384.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11662.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25828.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25673.24, "90th_percentile": 25673.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25673.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11418.01, "90th_percentile": 11418.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11418.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 11461.95, "90th_percentile": 11461.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11461.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "501", "type": "MS-DRG" } ], "description": "Soft Tissue Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 39501.62, "minimum": 14786.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39501.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35308.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36859.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33208.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31153.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14786.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32997.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 39459.72, "90th_percentile": 39459.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39459.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15325.72, "90th_percentile": 15325.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15325.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34310.52, "90th_percentile": 35055.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35049.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14188.41, "90th_percentile": 14188.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14188.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 31012.5, "90th_percentile": 31012.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31012.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12754.67, "90th_percentile": 12754.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12754.67, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14430.8, "90th_percentile": 14430.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14430.8, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14380.06, "90th_percentile": 14380.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14380.06, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35014.03, "90th_percentile": 35014.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35014.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9595.9, "90th_percentile": 9595.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9595.9, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30102.12, "90th_percentile": 30102.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30102.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14470.81, "90th_percentile": 14470.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14470.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31150.15, "90th_percentile": 32941.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31150.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "500", "type": "MS-DRG" } ], "description": "Soft Tissue Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 70122.07, "minimum": 25787.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70122.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 62679.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 65432.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58949.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55303.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25787.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58576.06 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22534.25, "90th_percentile": 22534.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22534.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 66073.73, "90th_percentile": 259318.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66073.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 30366.61, "90th_percentile": 30366.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30366.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7715.25, "90th_percentile": 7715.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7715.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 155885.9, "90th_percentile": 155885.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 155885.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14181.53, "90th_percentile": 14181.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14181.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 17908.41, "90th_percentile": 17908.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17908.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 165086.08, "90th_percentile": 165086.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 165086.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "499", "type": "MS-DRG" } ], "description": "Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25689.66, "minimum": 16857.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25689.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22962.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23971.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21596.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20260.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16857.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21459.71 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "498", "type": "MS-DRG" } ], "description": "Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 55874.14, "minimum": 24638.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55874.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49943.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 52137.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46972.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44066.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24638.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46674.13 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19938.17, "90th_percentile": 19938.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19938.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13854.96, "90th_percentile": 13854.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13854.96, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 70311.56, "90th_percentile": 70311.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 70311.56, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24375.84, "90th_percentile": 24375.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24375.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "497", "type": "MS-DRG" } ], "description": "Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29721.93, "minimum": 10594.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29721.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26567.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27734.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24986.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23440.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10594.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24828.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 11226.83, "90th_percentile": 11226.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11226.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43950.07, "90th_percentile": 43950.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43950.07, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11024.71, "90th_percentile": 11024.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11024.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "496", "type": "MS-DRG" } ], "description": "Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 43662.25, "minimum": 15219.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43662.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39027.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40742.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36705.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34435.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15219.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36473.0 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14117.85, "90th_percentile": 15816.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14117.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15373.06, "90th_percentile": 15373.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15373.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 1106.09, "90th_percentile": 1106.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1106.09, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13611.99, "90th_percentile": 13611.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13611.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36045.67, "90th_percentile": 36045.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36045.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13958.65, "90th_percentile": 13958.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13958.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "495", "type": "MS-DRG" } ], "description": "Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 77907.76, "minimum": 29367.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77907.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69638.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 72697.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65495.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61443.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29367.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65079.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27259.23, "90th_percentile": 27259.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27259.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27431.56, "90th_percentile": 27431.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27431.56, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "494", "type": "MS-DRG" } ], "description": "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41728.0, "minimum": 16792.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41728.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37298.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38937.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35079.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32909.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16792.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34857.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14892.87, "90th_percentile": 14892.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14892.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 47867.92, "90th_percentile": 47867.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47867.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33661.21, "90th_percentile": 41337.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37033.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 19730.47, "90th_percentile": 19730.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19730.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10399.06, "90th_percentile": 10399.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10399.06, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13186.93, "90th_percentile": 13186.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13186.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14230.55, "90th_percentile": 15105.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14230.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11394.55, "90th_percentile": 11394.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11394.55, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10141.33, "90th_percentile": 10141.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10141.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14243.65, "90th_percentile": 14243.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14243.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40365.16, "90th_percentile": 43455.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40365.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "493", "type": "MS-DRG" } ], "description": "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 53136.53, "minimum": 20905.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53136.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 47496.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 49583.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44670.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41907.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20905.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44387.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 62881.85, "90th_percentile": 69477.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62881.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17077.15, "90th_percentile": 19018.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17300.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 19733.8, "90th_percentile": 19733.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19733.8, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27528.34, "90th_percentile": 27528.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27528.34, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43466.48, "90th_percentile": 52882.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 46813.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4400.84, "90th_percentile": 4400.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4400.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17748.97, "90th_percentile": 19139.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17801.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11493.7, "90th_percentile": 20897.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11493.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 56539.5, "90th_percentile": 56539.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56539.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 16203.8, "90th_percentile": 16203.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16203.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16796.92, "90th_percentile": 20541.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 17736.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 53740.75, "90th_percentile": 53740.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53740.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 29935.63, "90th_percentile": 29935.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29935.63, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15277.05, "90th_percentile": 19153.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18557.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12188.36, "90th_percentile": 12697.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12697.8, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17671.46, "90th_percentile": 17671.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17671.46, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 58544.53, "90th_percentile": 58815.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58544.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 12041.02, "90th_percentile": 12041.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12041.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17398.31, "90th_percentile": 19160.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18054.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2132.0, "90th_percentile": 50787.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46962.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "492", "type": "MS-DRG" } ], "description": "Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 78587.18, "minimum": 29723.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78587.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70245.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 73331.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66066.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61979.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29723.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65647.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25258.72, "90th_percentile": 25258.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25258.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41234.94, "90th_percentile": 41234.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41234.94, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 294217.76, "90th_percentile": 294217.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 294217.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23634.28, "90th_percentile": 27650.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26472.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11493.7, "90th_percentile": 11493.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11493.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25136.54, "90th_percentile": 27688.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25136.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28689.03, "90th_percentile": 28689.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28689.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23436.63, "90th_percentile": 25990.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23473.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "489", "type": "MS-DRG" } ], "description": "Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27411.46, "minimum": 9883.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27411.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24501.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25578.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23044.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21618.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22898.0 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9797.46, "90th_percentile": 9797.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9797.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10990.07, "90th_percentile": 10990.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10990.07, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10321.59, "90th_percentile": 10321.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10321.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "488", "type": "MS-DRG" } ], "description": "Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43494.05, "minimum": 14947.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43494.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38877.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40585.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36564.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34302.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14947.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36332.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15708.53, "90th_percentile": 16830.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15708.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11493.7, "90th_percentile": 11493.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11493.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 244982.18, "90th_percentile": 244982.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 244982.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15721.23, "90th_percentile": 15721.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15721.23, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15625.49, "90th_percentile": 15625.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15625.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12697.8, "90th_percentile": 12697.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12697.8, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "487", "type": "MS-DRG" } ], "description": "Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34969.19, "minimum": 13373.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34969.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31257.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32630.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29397.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27579.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13373.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29211.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12797.88, "90th_percentile": 12797.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12797.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12839.78, "90th_percentile": 12839.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12839.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "486", "type": "MS-DRG" } ], "description": "Knee Procedures With Principal Diagnosis Of Infection With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 46933.21, "minimum": 17449.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46933.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41951.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43794.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39455.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37014.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17449.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39205.38 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 50209.42, "90th_percentile": 50209.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50209.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15379.99, "90th_percentile": 15379.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15379.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41658.72, "90th_percentile": 41658.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41658.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16875.71, "90th_percentile": 16875.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16875.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 12126.24, "90th_percentile": 12126.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12126.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16904.91, "90th_percentile": 16904.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16904.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "485", "type": "MS-DRG" } ], "description": "Knee Procedures With Principal Diagnosis Of Infection With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 71341.49, "minimum": 26271.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71341.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63769.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 66570.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59975.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56264.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26271.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59594.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25177.49, "90th_percentile": 25177.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25177.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "483", "type": "MS-DRG" } ], "description": "Major Joint Or Limb Reattachment Procedures Of Upper Extremities", "standard_charges": [ { "billing_class": "facility", "maximum": 56392.0, "minimum": 22736.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56392.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 52620.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47407.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44474.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22736.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47106.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20098.27, "90th_percentile": 20105.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20098.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 1982.99, "90th_percentile": 1982.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1982.99, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17963.86, "90th_percentile": 22444.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20134.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 68448.05, "90th_percentile": 68448.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68448.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19949.35, "90th_percentile": 20378.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19949.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 65117.54, "90th_percentile": 65152.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65117.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "482", "type": "MS-DRG" } ], "description": "Hip And Femur Procedures Except Major Joint Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35108.62, "minimum": 13876.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35108.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31382.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32760.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29514.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27689.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13876.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29327.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11729.81, "90th_percentile": 13241.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11752.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30741.35, "90th_percentile": 30741.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30741.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12881.75, "90th_percentile": 12881.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12881.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 12067.31, "90th_percentile": 12067.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12067.31, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10561.97, "90th_percentile": 10561.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10561.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11831.79, "90th_percentile": 11831.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11831.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "481", "type": "MS-DRG" } ], "description": "Hip And Femur Procedures Except Major Joint With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 45919.61, "minimum": 17476.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45919.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41045.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 42848.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38603.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36215.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17476.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38358.68 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 63299.94, "90th_percentile": 63299.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63299.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14689.57, "90th_percentile": 16588.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 15358.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 54806.57, "90th_percentile": 54806.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54806.57, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38074.91, "90th_percentile": 41261.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40755.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 12618.57, "90th_percentile": 12618.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12618.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14008.41, "90th_percentile": 16676.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 16528.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10799.68, "90th_percentile": 10799.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10799.68, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10470.36, "90th_percentile": 10470.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10470.36, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15136.13, "90th_percentile": 15136.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15136.13, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14039.01, "90th_percentile": 16599.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 15113.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46359.79, "90th_percentile": 46359.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46359.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14816.4, "90th_percentile": 16570.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16567.63, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11190.28, "90th_percentile": 16608.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15829.34, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16731.56, "90th_percentile": 16731.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16731.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15578.53, "90th_percentile": 16120.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15578.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50890.74, "90th_percentile": 50890.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50890.74, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 12504.89, "90th_percentile": 12504.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12504.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15208.48, "90th_percentile": 16796.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 16679.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40771.65, "90th_percentile": 50008.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44380.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "480", "type": "MS-DRG" } ], "description": "Hip And Femur Procedures Except Major Joint With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 65087.27, "minimum": 23826.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65087.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 58178.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 60734.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54717.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51332.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23826.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54370.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18075.88, "90th_percentile": 23127.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 21559.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61325.73, "90th_percentile": 61325.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61325.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16729.63, "90th_percentile": 23555.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20934.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15936.96, "90th_percentile": 37324.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18463.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 18343.03, "90th_percentile": 18343.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18343.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21288.52, "90th_percentile": 23127.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23066.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 23086.58, "90th_percentile": 23086.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23086.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 21457.96, "90th_percentile": 21457.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21457.96, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22246.7, "90th_percentile": 22246.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22246.7, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 16609.89, "90th_percentile": 16609.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16609.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20851.05, "90th_percentile": 23337.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 21524.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 57270.21, "90th_percentile": 57270.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57270.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "479", "type": "MS-DRG" } ], "description": "Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 39298.02, "minimum": 15646.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39298.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35126.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36669.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33036.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30993.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32827.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14400.98, "90th_percentile": 14400.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14400.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35128.88, "90th_percentile": 38297.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35128.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3750.76, "90th_percentile": 3750.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3750.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12649.05, "90th_percentile": 12649.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12649.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "478", "type": "MS-DRG" } ], "description": "Biopsies Of Musculoskeletal System And Connective Tissue With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 51751.13, "minimum": 20308.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51751.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46258.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 48290.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43505.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40814.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20308.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43230.0 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 46140.96, "90th_percentile": 46140.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46140.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17942.87, "90th_percentile": 19602.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18531.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 52763.56, "90th_percentile": 52763.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52763.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 18868.97, "90th_percentile": 18868.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18868.97, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46262.19, "90th_percentile": 51279.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46262.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17989.35, "90th_percentile": 18517.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17989.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 18861.63, "90th_percentile": 18861.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18861.63, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16904.06, "90th_percentile": 18573.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17573.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 61723.77, "90th_percentile": 61723.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61723.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 1657.67, "90th_percentile": 1657.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1657.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 20603.63, "90th_percentile": 20603.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20603.63, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17541.01, "90th_percentile": 17541.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17541.01, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44730.87, "90th_percentile": 44730.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44730.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15518.6, "90th_percentile": 17426.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15518.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "477", "type": "MS-DRG" } ], "description": "Biopsies Of Musculoskeletal System And Connective Tissue With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 76104.08, "minimum": 28038.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76104.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 68026.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 71014.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63978.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60020.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28038.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63573.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 76036.29, "90th_percentile": 76036.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76036.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23478.55, "90th_percentile": 25220.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24708.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 67295.56, "90th_percentile": 67295.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67295.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26016.1, "90th_percentile": 27501.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26894.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26442.15, "90th_percentile": 26931.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26816.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25433.17, "90th_percentile": 25433.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25433.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 60512.56, "90th_percentile": 60512.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60512.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "476", "type": "MS-DRG" } ], "description": "Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25738.35, "minimum": 10375.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25738.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23006.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24017.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21637.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20299.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10375.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21500.38 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21045.61, "90th_percentile": 21045.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21045.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "475", "type": "MS-DRG" } ], "description": "Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 47738.78, "minimum": 18883.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47738.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42671.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44546.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40132.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37650.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18883.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39878.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15085.75, "90th_percentile": 15183.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15085.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46678.3, "90th_percentile": 46678.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46678.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12298.5, "90th_percentile": 17150.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12298.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 15531.31, "90th_percentile": 15531.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15531.31, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10447.45, "90th_percentile": 10447.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10447.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15182.56, "90th_percentile": 15921.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15396.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 15795.28, "90th_percentile": 15795.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15795.28, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33322.78, "90th_percentile": 33322.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33322.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15541.3, "90th_percentile": 15541.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15541.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40955.78, "90th_percentile": 40955.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40955.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "474", "type": "MS-DRG" } ], "description": "Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 99244.26, "minimum": 34548.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99244.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 88710.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 92607.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83432.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78270.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34548.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 82903.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30910.69, "90th_percentile": 30910.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30910.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 24773.92, "90th_percentile": 24773.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24773.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14560.6, "90th_percentile": 14560.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14560.6, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34024.26, "90th_percentile": 34024.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34024.26, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25889.87, "90th_percentile": 25889.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25889.87, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32674.95, "90th_percentile": 32674.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32674.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "473", "type": "MS-DRG" } ], "description": "Cervical Spinal Fusion Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 52388.5, "minimum": 20169.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52388.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46827.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 48885.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44041.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41317.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20169.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43762.43 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1746.49, "90th_percentile": 15414.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1746.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46500.47, "90th_percentile": 50793.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46831.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17092.08, "90th_percentile": 17092.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17092.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 20721.15, "90th_percentile": 20721.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20721.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16596.08, "90th_percentile": 16596.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16596.08, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18295.13, "90th_percentile": 19783.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18692.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 51020.28, "90th_percentile": 80725.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51642.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 33935.84, "90th_percentile": 33935.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33935.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 18257.28, "90th_percentile": 18257.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18257.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18425.38, "90th_percentile": 18425.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18425.38, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50836.89, "90th_percentile": 62085.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51698.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 17386.37, "90th_percentile": 17386.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17386.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17435.13, "90th_percentile": 19280.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18893.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50901.07, "90th_percentile": 58955.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57317.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "472", "type": "MS-DRG" } ], "description": "Cervical Spinal Fusion With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 64113.51, "minimum": 24089.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64113.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57308.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 59825.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53898.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50564.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24089.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53556.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 75195.28, "90th_percentile": 75195.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75195.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20691.7, "90th_percentile": 22827.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 21329.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 64027.02, "90th_percentile": 64027.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64027.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18334.72, "90th_percentile": 18334.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18334.72, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 56906.8, "90th_percentile": 60695.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 57312.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 17544.43, "90th_percentile": 17544.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17544.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21087.72, "90th_percentile": 23617.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 22407.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 33075.12, "90th_percentile": 62284.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37049.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 17702.48, "90th_percentile": 17702.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17702.48, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41925.17, "90th_percentile": 41925.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41925.17, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16596.08, "90th_percentile": 16596.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 16596.08, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 99361.64, "90th_percentile": 99361.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99361.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 77799.63, "90th_percentile": 83446.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77799.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 23837.07, "90th_percentile": 23837.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23837.07, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 25712.35, "90th_percentile": 25712.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25712.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20588.84, "90th_percentile": 23186.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 21630.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 71176.15, "90th_percentile": 71176.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71176.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18334.72, "90th_percentile": 25803.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18334.72, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 59610.12, "90th_percentile": 81770.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72222.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 24382.4, "90th_percentile": 24382.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24382.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21025.9, "90th_percentile": 23483.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 21861.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 59555.47, "90th_percentile": 82572.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69814.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "471", "type": "MS-DRG" } ], "description": "Cervical Spinal Fusion With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 107490.27, "minimum": 38709.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 107490.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 96081.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 100301.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90364.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84774.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38709.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 89791.36 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 128852.99, "90th_percentile": 128852.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 128852.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36817.96, "90th_percentile": 36817.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36817.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 80971.75, "90th_percentile": 99480.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80971.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35369.19, "90th_percentile": 37512.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35672.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 90613.8, "90th_percentile": 90613.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90613.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34199.54, "90th_percentile": 37951.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35413.06, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 3442.99, "90th_percentile": 3442.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3442.99, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40552.58, "90th_percentile": 40552.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40552.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3442.99, "90th_percentile": 3442.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3442.99, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36150.7, "90th_percentile": 36677.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36177.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 97551.68, "90th_percentile": 97551.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 97551.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "470", "type": "MS-DRG" } ], "description": "Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41728.0, "minimum": 16190.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41728.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37298.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38937.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35079.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32909.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16190.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34857.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 53574.31, "90th_percentile": 103902.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53574.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12275.2, "90th_percentile": 15133.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 15105.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37298.96, "90th_percentile": 39316.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39316.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13457.86, "90th_percentile": 15727.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14483.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 18842.58, "90th_percentile": 18842.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18842.58, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15424.07, "90th_percentile": 15424.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15424.07, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14662.5, "90th_percentile": 15736.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15137.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44370.95, "90th_percentile": 44370.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44370.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13769.56, "90th_percentile": 13769.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13769.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 15109.05, "90th_percentile": 15109.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15109.05, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13767.9, "90th_percentile": 15287.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14595.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43486.9, "90th_percentile": 49682.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43486.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "469", "type": "MS-DRG" } ], "description": "Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl", "standard_charges": [ { "billing_class": "facility", "maximum": 72335.17, "minimum": 24765.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72335.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 64657.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 67497.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60810.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57048.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24765.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60424.76 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21142.38, "90th_percentile": 25570.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21874.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 20975.6, "90th_percentile": 20975.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20975.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24006.98, "90th_percentile": 24006.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24006.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 30637.79, "90th_percentile": 30637.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30637.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23828.67, "90th_percentile": 23828.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23828.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24294.02, "90th_percentile": 24294.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24294.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "468", "type": "MS-DRG" } ], "description": "Revision Of Hip Or Knee Replacement Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 58054.04, "minimum": 22551.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58054.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51892.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 54171.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48804.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45785.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22551.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48495.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18807.34, "90th_percentile": 21913.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20672.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 51894.12, "90th_percentile": 51894.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51894.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19021.98, "90th_percentile": 22114.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20812.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 41139.61, "90th_percentile": 41139.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41139.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10522.24, "90th_percentile": 10522.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10522.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 21889.82, "90th_percentile": 21889.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21889.82, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20663.84, "90th_percentile": 22109.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20672.47, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 58776.19, "90th_percentile": 58776.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58776.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 24441.54, "90th_percentile": 24441.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24441.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 21914.84, "90th_percentile": 21914.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21914.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 63189.61, "90th_percentile": 63189.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63189.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20353.06, "90th_percentile": 20353.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20353.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "467", "type": "MS-DRG" } ], "description": "Revision Of Hip Or Knee Replacement With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 75796.46, "minimum": 28597.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75796.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67751.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 70727.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63720.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59778.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28597.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63316.13 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 90613.9, "90th_percentile": 90613.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90613.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23264.49, "90th_percentile": 27789.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 26691.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 71072.27, "90th_percentile": 71422.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71072.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26707.33, "90th_percentile": 27733.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26712.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 38674.6, "90th_percentile": 38674.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38674.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 82116.95, "90th_percentile": 82116.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82116.95, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24987.31, "90th_percentile": 26721.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26687.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 79366.05, "90th_percentile": 82116.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79366.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 53885.97, "90th_percentile": 53885.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53885.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 25319.25, "90th_percentile": 26832.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25669.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 71535.29, "90th_percentile": 191474.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71887.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26665.28, "90th_percentile": 27072.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27038.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 66731.76, "90th_percentile": 66731.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66731.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "466", "type": "MS-DRG" } ], "description": "Revision Of Hip Or Knee Replacement With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 112741.95, "minimum": 41634.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112741.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 100775.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 105202.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94779.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88915.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41634.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94178.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35190.03, "90th_percentile": 35228.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35190.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 38482.02, "90th_percentile": 38482.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38482.02, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39284.46, "90th_percentile": 39302.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39284.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37030.38, "90th_percentile": 38760.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38068.2, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 236205.77, "90th_percentile": 236205.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 236205.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 51786.48, "90th_percentile": 51786.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51786.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 37734.1, "90th_percentile": 37734.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37734.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "465", "type": "MS-DRG" } ], "description": "Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit", "standard_charges": [ { "billing_class": "facility", "maximum": 38417.2, "minimum": 15373.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38417.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34339.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35848.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32296.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30298.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32091.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34343.53, "90th_percentile": 34343.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34343.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11719.55, "90th_percentile": 11719.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11719.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "464", "type": "MS-DRG" } ], "description": "Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit", "standard_charges": [ { "billing_class": "facility", "maximum": 65255.47, "minimum": 25398.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65255.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 58329.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 60891.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54858.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51464.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25398.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54510.77 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 65224.67, "90th_percentile": 65224.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65224.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21585.71, "90th_percentile": 21585.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21585.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 58329.21, "90th_percentile": 58329.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58329.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5428.08, "90th_percentile": 5428.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5428.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24936.67, "90th_percentile": 24936.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24936.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 78781.65, "90th_percentile": 78781.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78781.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10473.31, "90th_percentile": 10473.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10473.31, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 66336.58, "90th_percentile": 66336.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66336.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23129.36, "90th_percentile": 23136.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23129.36, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8356.47, "90th_percentile": 8356.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8356.47, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22301.26, "90th_percentile": 23929.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22301.26, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23952.01, "90th_percentile": 23952.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23952.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 63981.04, "90th_percentile": 167949.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63981.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "463", "type": "MS-DRG" } ], "description": "Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit", "standard_charges": [ { "billing_class": "facility", "maximum": 119522.89, "minimum": 45471.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 119522.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 106836.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 111529.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100480.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94263.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45471.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99842.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30007.49, "90th_percentile": 30007.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30007.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 371291.98, "90th_percentile": 371291.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 371291.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41656.27, "90th_percentile": 41656.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41656.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8757.02, "90th_percentile": 8757.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8757.02, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41612.87, "90th_percentile": 41773.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41612.87, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 320519.54, "90th_percentile": 320519.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 320519.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 106060.18, "90th_percentile": 106060.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 106060.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 25826.64, "90th_percentile": 25826.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25826.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "462", "type": "MS-DRG" } ], "description": "Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 63374.33, "minimum": 21867.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63374.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 56647.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 59136.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53277.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49981.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21867.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52939.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 56250.76, "90th_percentile": 58860.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56250.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18612.61, "90th_percentile": 18612.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18612.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "461", "type": "MS-DRG" } ], "description": "Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 135811.31, "minimum": 44101.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 135811.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 121396.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 126728.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 114173.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 107109.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44101.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 113449.17 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "458", "type": "MS-DRG" } ], "description": "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With", "standard_charges": [ { "billing_class": "facility", "maximum": 95555.02, "minimum": 33614.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95555.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 85412.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 89164.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80330.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75361.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33614.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79821.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33711.62, "90th_percentile": 33711.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33711.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31671.14, "90th_percentile": 31671.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31671.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33529.39, "90th_percentile": 33529.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33529.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "457", "type": "MS-DRG" } ], "description": "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With", "standard_charges": [ { "billing_class": "facility", "maximum": 127009.81, "minimum": 47518.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127009.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 113528.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 118516.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106774.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100168.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47518.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 106096.89 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50456.92, "90th_percentile": 50456.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50456.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27465.35, "90th_percentile": 27465.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27465.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 108240.24, "90th_percentile": 108240.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108240.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 64378.82, "90th_percentile": 64378.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64378.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46029.96, "90th_percentile": 46029.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46029.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 33990.4, "90th_percentile": 33990.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33990.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 61643.54, "90th_percentile": 61643.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61643.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 43201.54, "90th_percentile": 43201.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43201.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44255.96, "90th_percentile": 44255.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44255.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44566.6, "90th_percentile": 44566.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44566.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 130411.19, "90th_percentile": 130411.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 130411.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "456", "type": "MS-DRG" } ], "description": "Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With", "standard_charges": [ { "billing_class": "facility", "maximum": 187418.59, "minimum": 66469.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 187418.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 167525.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 174885.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 157558.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147810.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66469.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156559.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 169672.73, "90th_percentile": 169672.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 169672.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 58800.72, "90th_percentile": 58800.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58800.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38855.34, "90th_percentile": 38855.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38855.34, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 500.0, "90th_percentile": 500.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 500.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61374.75, "90th_percentile": 63426.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63080.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 24860.88, "90th_percentile": 24860.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24860.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 64749.54, "90th_percentile": 64749.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64749.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 209603.4, "90th_percentile": 209603.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 209603.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 36845.58, "90th_percentile": 36845.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36845.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63840.02, "90th_percentile": 65339.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63840.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "451", "type": "MS-DRG" } ], "description": "Single Level Spinal Fusion Except Cervical Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 68291.84, "minimum": 26297.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68291.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 61043.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 63724.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57411.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53859.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26297.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57047.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 84628.01, "90th_percentile": 84628.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84628.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23926.76, "90th_percentile": 24273.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24174.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27465.35, "90th_percentile": 27465.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27465.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60615.21, "90th_percentile": 66552.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 61047.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 26281.5, "90th_percentile": 26281.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26281.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21966.69, "90th_percentile": 24153.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23386.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 59806.19, "90th_percentile": 59806.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59806.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 22369.44, "90th_percentile": 22493.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22369.44, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32930.15, "90th_percentile": 32930.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32930.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 20971.35, "90th_percentile": 24860.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20971.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 79224.38, "90th_percentile": 79224.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79224.38, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 24621.7, "90th_percentile": 24621.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24621.7, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 27465.35, "90th_percentile": 35136.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27465.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24222.14, "90th_percentile": 24246.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24222.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 71816.88, "90th_percentile": 81912.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76330.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 24442.22, "90th_percentile": 24442.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24442.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23168.34, "90th_percentile": 38855.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27465.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 23978.39, "90th_percentile": 23978.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23978.39, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 66750.89, "90th_percentile": 66750.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66750.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 21969.98, "90th_percentile": 21969.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21969.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14919.65, "90th_percentile": 24467.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 22630.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 70418.12, "90th_percentile": 87702.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79392.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "450", "type": "MS-DRG" } ], "description": "Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F", "standard_charges": [ { "billing_class": "facility", "maximum": 113968.01, "minimum": 42599.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113968.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 101871.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 106346.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95810.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 89882.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42599.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 95202.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38855.34, "90th_percentile": 38855.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38855.34, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 101158.26, "90th_percentile": 101158.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 101158.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 18120.53, "90th_percentile": 18120.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18120.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39753.23, "90th_percentile": 39753.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39753.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 35170.78, "90th_percentile": 35170.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35170.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 133219.64, "90th_percentile": 133219.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 133219.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 153452.11, "90th_percentile": 153452.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 153452.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40235.99, "90th_percentile": 40896.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40235.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "448", "type": "MS-DRG" } ], "description": "Multiple Level Spinal Fusion Except Cervical Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 90365.3, "minimum": 34143.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90365.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 80773.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 84322.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75967.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71268.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34143.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75486.12 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 129077.44, "90th_percentile": 129077.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 129077.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29604.24, "90th_percentile": 39772.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 31691.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 79454.56, "90th_percentile": 224470.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 84700.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 26330.3, "90th_percentile": 26330.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26330.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29550.4, "90th_percentile": 32867.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 31668.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 38397.79, "90th_percentile": 45359.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38397.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 22369.44, "90th_percentile": 26518.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22369.44, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 20971.35, "90th_percentile": 35170.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24860.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 108288.39, "90th_percentile": 108288.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108288.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 123532.09, "90th_percentile": 201856.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 126630.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 30443.41, "90th_percentile": 32660.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30443.41, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 27465.35, "90th_percentile": 27465.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27465.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29422.77, "90th_percentile": 33502.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 31676.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 107123.12, "90th_percentile": 118906.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 107123.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 90795.42, "90th_percentile": 90795.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90795.42, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 29777.77, "90th_percentile": 29777.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29777.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 3033.83, "90th_percentile": 3033.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3033.83, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27465.35, "90th_percentile": 37460.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27465.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 168562.97, "90th_percentile": 168562.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 168562.97, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 107729.88, "90th_percentile": 171760.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 145601.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 26044.73, "90th_percentile": 26130.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26044.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27144.84, "90th_percentile": 41699.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 31913.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 84731.94, "90th_percentile": 175299.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 96291.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "447", "type": "MS-DRG" } ], "description": "Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody", "standard_charges": [ { "billing_class": "facility", "maximum": 148370.65, "minimum": 53098.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 148370.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 132622.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 138448.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 124731.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117015.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53098.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 123940.55 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50044.8, "90th_percentile": 51606.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51411.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 53299.78, "90th_percentile": 53299.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53299.78, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 343052.99, "90th_percentile": 343052.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 343052.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40783.87, "90th_percentile": 53932.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49779.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 45809.98, "90th_percentile": 45809.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45809.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 35170.78, "90th_percentile": 48245.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35170.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 149071.35, "90th_percentile": 149071.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 149071.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49445.02, "90th_percentile": 49445.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49445.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 49039.21, "90th_percentile": 49039.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49039.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 4779.96, "90th_percentile": 4779.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4779.96, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23569.77, "90th_percentile": 23569.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23569.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 319547.15, "90th_percentile": 319547.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 319547.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50586.55, "90th_percentile": 51924.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50620.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 170746.5, "90th_percentile": 170746.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 170746.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "446", "type": "MS-DRG" } ], "description": "Disorders Of The Biliary Tract Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17642.83, "minimum": 7635.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17642.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15770.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16462.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14831.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13914.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7635.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14737.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15999.93, "90th_percentile": 19358.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17628.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6903.85, "90th_percentile": 6903.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6903.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 7097.53, "90th_percentile": 7097.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7097.53, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13660.57, "90th_percentile": 17250.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 15772.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6274.54, "90th_percentile": 6274.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6274.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 13241.42, "90th_percentile": 13241.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13241.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6230.58, "90th_percentile": 6230.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6230.58, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4493.57, "90th_percentile": 4493.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4493.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 16426.47, "90th_percentile": 16426.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16426.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4000.0, "90th_percentile": 4000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4000.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6453.1, "90th_percentile": 6453.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6453.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5168.66, "90th_percentile": 5168.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5168.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14982.83, "90th_percentile": 14982.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14982.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 6918.13, "90th_percentile": 6918.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6918.13, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6453.1, "90th_percentile": 6453.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6453.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14068.4, "90th_percentile": 14068.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14068.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6119.32, "90th_percentile": 6119.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6119.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5021.24, "90th_percentile": 5021.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5021.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12557.41, "90th_percentile": 14716.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12557.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "445", "type": "MS-DRG" } ], "description": "Disorders Of The Biliary Tract With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23998.86, "minimum": 9709.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23998.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21451.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22393.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20175.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18927.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9709.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20047.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 19100.48, "90th_percentile": 19100.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19100.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6762.22, "90th_percentile": 9062.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 8297.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7248.07, "90th_percentile": 7248.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7248.07, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18430.08, "90th_percentile": 22546.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21301.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7484.76, "90th_percentile": 9071.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 7986.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 9565.73, "90th_percentile": 25738.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12843.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2709.96, "90th_percentile": 2709.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2709.96, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3963.81, "90th_percentile": 8158.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5222.9, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 44610.84, "90th_percentile": 44610.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44610.84, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8203.37, "90th_percentile": 8203.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8203.37, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7369.7, "90th_percentile": 9084.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 7565.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20698.99, "90th_percentile": 21584.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21086.35, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 8610.6, "90th_percentile": 8610.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8610.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8552.47, "90th_percentile": 8552.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8552.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 9097.14, "90th_percentile": 9097.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9097.14, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5054.99, "90th_percentile": 5054.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5054.99, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17115.2, "90th_percentile": 20017.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18928.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6119.32, "90th_percentile": 6119.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6119.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7382.7, "90th_percentile": 9518.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 8372.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20017.7, "90th_percentile": 20200.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20017.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "444", "type": "MS-DRG" } ], "description": "Disorders Of The Biliary Tract With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 37279.67, "minimum": 14186.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37279.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33322.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34786.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31340.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29401.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14186.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31141.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11697.31, "90th_percentile": 13622.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 12381.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 11079.78, "90th_percentile": 11079.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11079.78, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31391.18, "90th_percentile": 34423.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33084.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11168.74, "90th_percentile": 13596.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12002.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 16198.85, "90th_percentile": 16198.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16198.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4725.48, "90th_percentile": 16087.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4725.48, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5278.27, "90th_percentile": 17780.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9284.96, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32229.41, "90th_percentile": 32229.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32229.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 12561.66, "90th_percentile": 12880.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12561.66, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11442.33, "90th_percentile": 13908.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 12519.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33466.82, "90th_percentile": 45086.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33466.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12517.97, "90th_percentile": 12517.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12517.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29551.85, "90th_percentile": 29551.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29551.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8547.26, "90th_percentile": 8547.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8547.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13707.53, "90th_percentile": 13937.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13707.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25381.52, "90th_percentile": 32319.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29187.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "443", "type": "MS-DRG" } ], "description": "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15549.24, "minimum": 6644.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15549.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13898.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14509.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13071.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12263.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6644.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12988.97 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13530.14, "90th_percentile": 13530.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13530.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4957.77, "90th_percentile": 4957.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4957.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6196.01, "90th_percentile": 6196.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6196.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4443.25, "90th_percentile": 4443.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4443.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9861.92, "90th_percentile": 9861.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9861.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12970.44, "90th_percentile": 12970.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12970.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "442", "type": "MS-DRG" } ], "description": "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 21382.97, "minimum": 8706.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21382.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19113.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19953.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17976.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16864.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8706.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17862.14 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6948.38, "90th_percentile": 7995.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7508.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5181.09, "90th_percentile": 5181.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5181.09, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12481.11, "90th_percentile": 18978.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 18480.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6385.43, "90th_percentile": 6385.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6385.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6648.38, "90th_percentile": 8457.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8236.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 7384.16, "90th_percentile": 7384.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7384.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5002.44, "90th_percentile": 7981.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5002.44, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5389.5, "90th_percentile": 5389.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5389.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8616.09, "90th_percentile": 8616.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8616.09, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4443.25, "90th_percentile": 4443.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4443.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6316.28, "90th_percentile": 7808.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7229.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20510.22, "90th_percentile": 20510.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20510.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 22368.18, "90th_percentile": 37357.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22368.18, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8028.59, "90th_percentile": 8028.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8028.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4986.68, "90th_percentile": 4986.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4986.68, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4548.04, "90th_percentile": 4548.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4548.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6566.25, "90th_percentile": 7640.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6703.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17817.51, "90th_percentile": 17940.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17817.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "441", "type": "MS-DRG" } ], "description": "Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41834.23, "minimum": 15147.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41834.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37393.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39036.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35169.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32993.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15147.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34945.98 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8655.54, "90th_percentile": 15148.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13544.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32258.03, "90th_percentile": 37395.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36974.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9002.24, "90th_percentile": 17490.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9002.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13431.39, "90th_percentile": 15208.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15138.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 35819.14, "90th_percentile": 35819.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35819.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 17647.99, "90th_percentile": 17647.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17647.99, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19629.31, "90th_percentile": 19629.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19629.31, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6122.34, "90th_percentile": 16244.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7482.73, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13718.85, "90th_percentile": 13718.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13718.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21673.51, "90th_percentile": 21673.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21673.51, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5647.36, "90th_percentile": 5647.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5647.36, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10613.83, "90th_percentile": 15155.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12883.21, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37087.76, "90th_percentile": 37087.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37087.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9790.96, "90th_percentile": 9790.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9790.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 17032.46, "90th_percentile": 17032.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17032.46, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32995.04, "90th_percentile": 32995.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32995.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7535.75, "90th_percentile": 7925.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7535.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9814.15, "90th_percentile": 15297.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13364.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32995.04, "90th_percentile": 33126.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32995.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "440", "type": "MS-DRG" } ], "description": "Disorders Of Pancreas Except Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 13612.78, "minimum": 6036.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13612.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12167.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12702.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11443.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10735.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6036.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11371.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3981.85, "90th_percentile": 5087.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5080.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13612.78, "90th_percentile": 13612.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13612.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12081.79, "90th_percentile": 12826.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12081.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4323.74, "90th_percentile": 4323.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4323.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4410.02, "90th_percentile": 4410.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4410.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4927.46, "90th_percentile": 13899.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6552.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3891.62, "90th_percentile": 4362.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4362.69, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4090.02, "90th_percentile": 5154.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4172.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12520.21, "90th_percentile": 12520.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12520.21, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 12702.43, "90th_percentile": 12702.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12702.43, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 17562.05, "90th_percentile": 17562.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17562.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 4348.29, "90th_percentile": 4348.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4348.29, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9037.0, "90th_percentile": 9037.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9037.0, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4596.03, "90th_percentile": 5519.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4596.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10223.82, "90th_percentile": 10223.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10223.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 4162.38, "90th_percentile": 4162.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4162.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 5533.43, "90th_percentile": 5533.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5533.43, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4284.79, "90th_percentile": 4284.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4284.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3561.55, "90th_percentile": 3561.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3561.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10735.96, "90th_percentile": 11353.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10735.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "439", "type": "MS-DRG" } ], "description": "Disorders Of Pancreas Except Malignancy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 19037.09, "minimum": 7743.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19037.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17016.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17763.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16004.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15013.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15902.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 14539.42, "90th_percentile": 19668.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14539.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6409.51, "90th_percentile": 7429.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7368.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20722.08, "90th_percentile": 20722.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20722.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5604.01, "90th_percentile": 8460.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5604.01, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12100.65, "90th_percentile": 17936.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 16896.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4633.81, "90th_percentile": 4633.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4633.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5815.18, "90th_percentile": 11318.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6152.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 10288.82, "90th_percentile": 10288.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10288.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7086.31, "90th_percentile": 28689.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7086.31, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4090.02, "90th_percentile": 5072.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 4172.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39014.34, "90th_percentile": 39014.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39014.34, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 18283.48, "90th_percentile": 18696.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18283.48, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4751.87, "90th_percentile": 8460.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5604.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5444.04, "90th_percentile": 7591.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7159.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36050.65, "90th_percentile": 36050.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36050.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 11136.33, "90th_percentile": 11136.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11136.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4751.87, "90th_percentile": 5694.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5604.01, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7685.66, "90th_percentile": 7685.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7685.66, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12422.51, "90th_percentile": 15369.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12422.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5314.14, "90th_percentile": 5314.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5314.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5896.8, "90th_percentile": 7431.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6191.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15877.57, "90th_percentile": 15877.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15877.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "438", "type": "MS-DRG" } ], "description": "Disorders Of Pancreas Except Malignancy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36821.56, "minimum": 13870.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36821.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32913.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34359.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30955.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29039.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13870.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30758.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 23702.75, "90th_percentile": 23702.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23702.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11535.41, "90th_percentile": 13437.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13233.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15300.8, "90th_percentile": 15300.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15300.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 12310.26, "90th_percentile": 12310.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12310.26, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8460.49, "90th_percentile": 8460.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8460.49, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17917.9, "90th_percentile": 32911.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 28564.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 2306.94, "90th_percentile": 2306.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2306.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11295.63, "90th_percentile": 13454.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11988.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 27857.33, "90th_percentile": 27857.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27857.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7003.11, "90th_percentile": 7003.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7003.11, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4090.02, "90th_percentile": 17950.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7658.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 25859.5, "90th_percentile": 30673.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25859.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11467.53, "90th_percentile": 13503.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12362.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30584.35, "90th_percentile": 41588.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30584.35, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13434.63, "90th_percentile": 13434.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13434.63, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5694.67, "90th_percentile": 8460.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5694.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12274.98, "90th_percentile": 12274.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12274.98, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 13697.06, "90th_percentile": 13697.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13697.06, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14849.0, "90th_percentile": 14849.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14849.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8022.88, "90th_percentile": 8022.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8022.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12153.51, "90th_percentile": 24887.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13550.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29038.22, "90th_percentile": 34500.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29292.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "437", "type": "MS-DRG" } ], "description": "Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17375.05, "minimum": 7837.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17375.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15530.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16213.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14606.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13703.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7837.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14514.14 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14887.02, "90th_percentile": 14887.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14887.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13638.27, "90th_percentile": 13638.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13638.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6866.16, "90th_percentile": 6866.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6866.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "436", "type": "MS-DRG" } ], "description": "Malignancy Of Hepatobiliary System Or Pancreas With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 24954.92, "minimum": 9994.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24954.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22306.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23286.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20979.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19681.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9994.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20845.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7466.66, "90th_percentile": 9411.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 8646.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18926.8, "90th_percentile": 23585.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21682.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8257.57, "90th_percentile": 9385.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8257.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6195.09, "90th_percentile": 6195.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6195.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 24843.81, "90th_percentile": 24843.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24843.81, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8483.6, "90th_percentile": 9708.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9173.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 16002.6, "90th_percentile": 16002.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16002.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8082.14, "90th_percentile": 8082.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8082.14, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20710.44, "90th_percentile": 20710.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20710.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6490.1, "90th_percentile": 8359.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6490.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7109.66, "90th_percentile": 9471.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8340.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1972.8, "90th_percentile": 1972.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1972.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "435", "type": "MS-DRG" } ], "description": "Malignancy Of Hepatobiliary System Or Pancreas With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40378.01, "minimum": 15474.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40378.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36092.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37677.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33944.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31844.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15474.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33729.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 36473.38, "90th_percentile": 43212.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39833.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12411.64, "90th_percentile": 14673.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 13399.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42943.88, "90th_percentile": 42943.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42943.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31040.95, "90th_percentile": 59608.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 35838.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9541.07, "90th_percentile": 9541.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9541.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12906.36, "90th_percentile": 14641.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 14303.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 20113.6, "90th_percentile": 20113.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20113.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7219.6, "90th_percentile": 8576.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7219.6, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4968.85, "90th_percentile": 7979.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7979.56, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14733.8, "90th_percentile": 14733.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14733.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20417.99, "90th_percentile": 20417.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20417.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 78939.83, "90th_percentile": 78939.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78939.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14089.47, "90th_percentile": 14954.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14913.54, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6844.1, "90th_percentile": 6844.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6844.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12380.61, "90th_percentile": 15170.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 13580.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35796.83, "90th_percentile": 179727.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35796.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 50236.73, "90th_percentile": 50236.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50236.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 1293.33, "90th_percentile": 42142.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14082.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 14708.59, "90th_percentile": 16069.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14708.59, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8815.51, "90th_percentile": 8815.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8815.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22095.79, "90th_percentile": 22095.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22095.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13207.07, "90th_percentile": 14804.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 13655.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31846.57, "90th_percentile": 35547.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32100.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "434", "type": "MS-DRG" } ], "description": "Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15412.03, "minimum": 6743.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15412.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13776.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14381.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12956.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12154.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6743.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12874.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13680.65, "90th_percentile": 13680.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13680.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3722.03, "90th_percentile": 3722.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3722.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "433", "type": "MS-DRG" } ], "description": "Cirrhosis And Alcoholic Hepatitis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23673.53, "minimum": 9412.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23673.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21160.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22090.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19901.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18670.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9412.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19775.54 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 25012.99, "90th_percentile": 26017.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25012.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6542.57, "90th_percentile": 8966.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7827.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4152.27, "90th_percentile": 4152.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4152.27, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18353.75, "90th_percentile": 22307.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 21013.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4957.77, "90th_percentile": 7910.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5403.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7928.22, "90th_percentile": 9110.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 8944.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4134.58, "90th_percentile": 22376.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13779.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4317.39, "90th_percentile": 6770.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5452.62, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8343.9, "90th_percentile": 12374.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8343.9, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3722.03, "90th_percentile": 7482.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4689.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29820.52, "90th_percentile": 29820.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29820.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 22956.51, "90th_percentile": 22956.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22956.51, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5647.36, "90th_percentile": 8357.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5647.36, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7086.84, "90th_percentile": 8948.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 8041.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20813.81, "90th_percentile": 20988.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20813.81, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 885.6, "90th_percentile": 9245.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 885.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 788.04, "90th_percentile": 788.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 788.04, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5647.36, "90th_percentile": 5738.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5647.36, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7860.98, "90th_percentile": 7860.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7860.98, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18672.29, "90th_percentile": 19746.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18672.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5441.23, "90th_percentile": 15310.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5441.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7496.62, "90th_percentile": 9227.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8007.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15382.47, "90th_percentile": 19495.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 18672.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "432", "type": "MS-DRG" } ], "description": "Cirrhosis And Alcoholic Hepatitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43356.84, "minimum": 16495.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43356.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38754.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40457.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36449.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34194.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16495.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36217.88 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 32554.25, "90th_percentile": 46018.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42172.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1443.12, "90th_percentile": 15685.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 14436.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 15539.98, "90th_percentile": 15539.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15539.98, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5647.36, "90th_percentile": 10707.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8266.64, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20243.25, "90th_percentile": 40851.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 38480.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7910.32, "90th_percentile": 18102.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 7910.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13219.8, "90th_percentile": 16171.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 15119.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8997.74, "90th_percentile": 63662.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 18740.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4699.24, "90th_percentile": 14697.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6844.34, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19912.53, "90th_percentile": 19912.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19912.53, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5111.83, "90th_percentile": 17041.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 7482.73, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25159.86, "90th_percentile": 25159.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25159.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 160841.26, "90th_percentile": 160841.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 160841.26, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13821.65, "90th_percentile": 15946.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13821.65, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5339.33, "90th_percentile": 18827.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 8266.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13562.98, "90th_percentile": 15684.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 14671.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35031.82, "90th_percentile": 38614.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 38435.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14110.58, "90th_percentile": 30477.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15655.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 15761.46, "90th_percentile": 125414.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15761.46, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5647.36, "90th_percentile": 18827.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 8266.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14966.5, "90th_percentile": 16175.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14966.5, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34194.13, "90th_percentile": 36161.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34194.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4999.08, "90th_percentile": 7925.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6274.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13470.48, "90th_percentile": 15845.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 14725.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34188.84, "90th_percentile": 194700.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34194.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "430", "type": "MS-DRG" } ], "description": "Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 121058.78, "minimum": 45996.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 121058.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 108209.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 112963.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101771.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95475.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45996.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 101125.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 121222.3, "90th_percentile": 121222.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121222.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41358.92, "90th_percentile": 41358.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41358.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 78210.23, "90th_percentile": 78210.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78210.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 24860.88, "90th_percentile": 24860.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24860.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 120089.04, "90th_percentile": 120089.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 120089.04, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42181.02, "90th_percentile": 42181.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42181.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "398", "type": "MS-DRG" } ], "description": "Appendix Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 33490.84, "minimum": 12964.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33490.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29936.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31251.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28154.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26413.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12964.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27976.38 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 33324.84, "90th_percentile": 33456.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33324.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12326.89, "90th_percentile": 12326.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12326.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29722.27, "90th_percentile": 29934.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29722.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7715.11, "90th_percentile": 7715.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7715.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11944.91, "90th_percentile": 11944.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11944.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 71832.01, "90th_percentile": 71832.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71832.01, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8097.3, "90th_percentile": 8097.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8097.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25844.1, "90th_percentile": 26141.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25844.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12042.78, "90th_percentile": 12042.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12042.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26083.7, "90th_percentile": 26083.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26083.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "397", "type": "MS-DRG" } ], "description": "Appendix Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 54831.77, "minimum": 19808.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54831.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49011.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 51164.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46095.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43244.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19808.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45803.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 17761.85, "90th_percentile": 17761.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17761.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 14991.09, "90th_percentile": 14991.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14991.09, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 18161.8, "90th_percentile": 18161.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18161.8, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19004.99, "90th_percentile": 19004.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19004.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41084.84, "90th_percentile": 41084.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41084.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42950.31, "90th_percentile": 42950.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42950.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "395", "type": "MS-DRG" } ], "description": "Other Digestive System Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14084.17, "minimum": 6250.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14084.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12589.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13142.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11840.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11107.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6250.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11765.13 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 14332.88, "90th_percentile": 21118.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14332.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12500.17, "90th_percentile": 13270.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12500.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5376.2, "90th_percentile": 5376.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5376.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8621.38, "90th_percentile": 8621.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8621.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5663.46, "90th_percentile": 6021.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5663.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5714.0, "90th_percentile": 5714.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5714.0, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12732.73, "90th_percentile": 12732.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12732.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11077.13, "90th_percentile": 11077.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11077.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6905.11, "90th_percentile": 6905.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6905.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5746.86, "90th_percentile": 5746.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5746.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7210.94, "90th_percentile": 12014.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11107.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "394", "type": "MS-DRG" } ], "description": "Other Digestive System Diagnoses With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 20831.91, "minimum": 8477.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20831.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18620.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19438.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17512.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16429.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8477.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17401.81 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 21798.25, "90th_percentile": 24060.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21798.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7318.36, "90th_percentile": 8002.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 7979.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6951.06, "90th_percentile": 6951.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6951.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16180.59, "90th_percentile": 28108.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 18489.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6431.1, "90th_percentile": 8240.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 7675.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 6792.74, "90th_percentile": 30694.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7537.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5963.5, "90th_percentile": 6423.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5963.5, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3729.6, "90th_percentile": 6591.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5745.53, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 20337.44, "90th_percentile": 20337.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20337.44, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8128.84, "90th_percentile": 8128.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8128.84, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6256.77, "90th_percentile": 6256.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6256.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6169.37, "90th_percentile": 8310.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 7783.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18021.66, "90th_percentile": 18467.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18467.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 32445.39, "90th_percentile": 32445.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32445.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 669.39, "90th_percentile": 7753.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6399.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7256.06, "90th_percentile": 8900.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7286.2, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7281.75, "90th_percentile": 7281.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7281.75, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16429.45, "90th_percentile": 17374.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17271.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5252.86, "90th_percentile": 7869.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6394.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 667.22, "90th_percentile": 8059.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 6634.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15196.89, "90th_percentile": 17374.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16429.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "393", "type": "MS-DRG" } ], "description": "Other Digestive System Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36646.72, "minimum": 13630.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36646.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32757.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34195.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30808.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28902.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13630.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30612.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 35082.37, "90th_percentile": 36648.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36648.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9956.12, "90th_percentile": 13407.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 12205.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34384.56, "90th_percentile": 34384.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34384.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 1173.82, "90th_percentile": 1173.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1173.82, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10020.45, "90th_percentile": 10020.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10020.45, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16836.9, "90th_percentile": 32758.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 32527.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12614.54, "90th_percentile": 13407.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 13274.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4699.72, "90th_percentile": 26933.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21213.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6591.24, "90th_percentile": 22546.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9152.3, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11843.24, "90th_percentile": 11843.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11843.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 17083.16, "90th_percentile": 17083.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17083.16, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11219.84, "90th_percentile": 13407.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 13363.24, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31457.65, "90th_percentile": 32489.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31457.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 21385.3, "90th_percentile": 21385.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21385.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 11648.56, "90th_percentile": 11648.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11648.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13379.25, "90th_percentile": 13379.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13379.25, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16859.83, "90th_percentile": 16950.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16859.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12214.86, "90th_percentile": 12214.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12214.86, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 14233.51, "90th_percentile": 14233.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14233.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11458.63, "90th_percentile": 13533.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 13491.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29157.71, "90th_percentile": 208356.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30566.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "392", "type": "MS-DRG" } ], "description": "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17268.82, "minimum": 7264.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17268.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15435.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16113.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14517.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13619.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7264.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14425.41 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13039.54, "90th_percentile": 18227.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 17252.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5122.94, "90th_percentile": 6821.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 6220.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15289.4, "90th_percentile": 15289.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15289.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 444.4, "90th_percentile": 444.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 444.4, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5539.38, "90th_percentile": 5686.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5539.38, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11653.03, "90th_percentile": 16061.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 15326.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4467.77, "90th_percentile": 6365.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5511.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5122.76, "90th_percentile": 7139.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 6232.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 6021.83, "90th_percentile": 23351.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11863.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4396.55, "90th_percentile": 6471.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4717.44, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8049.74, "90th_percentile": 8049.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8049.74, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4859.35, "90th_percentile": 6149.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 5214.02, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33786.35, "90th_percentile": 33786.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33786.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 16113.98, "90th_percentile": 24214.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16889.45, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 30307.9, "90th_percentile": 30307.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30307.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 6399.14, "90th_percentile": 6399.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6399.14, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5777.29, "90th_percentile": 5777.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5777.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5064.94, "90th_percentile": 7056.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 5881.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11645.86, "90th_percentile": 18096.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14517.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 5964.82, "90th_percentile": 6783.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6407.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 5170.33, "90th_percentile": 6652.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5170.33, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5241.49, "90th_percentile": 6652.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5760.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6238.82, "90th_percentile": 7316.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7044.52, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12153.88, "90th_percentile": 12153.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12153.88, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13619.36, "90th_percentile": 15308.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14389.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5548.28, "90th_percentile": 5548.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5548.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 814.26, "90th_percentile": 6849.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 5518.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11436.58, "90th_percentile": 14402.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 13729.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "391", "type": "MS-DRG" } ], "description": "Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28436.12, "minimum": 11059.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28436.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25417.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26534.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23905.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22426.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11059.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23753.95 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29373.44, "90th_percentile": 30032.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29373.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8495.21, "90th_percentile": 9844.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 9650.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28400.29, "90th_percentile": 28400.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28400.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7876.31, "90th_percentile": 10020.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8411.42, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17117.99, "90th_percentile": 26446.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 24511.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 15761.19, "90th_percentile": 15761.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15761.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8738.59, "90th_percentile": 10843.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 10561.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 24448.69, "90th_percentile": 24448.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24448.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8121.37, "90th_percentile": 8121.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8121.37, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15765.0, "90th_percentile": 15765.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15765.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3670.24, "90th_percentile": 9070.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 7613.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 52724.53, "90th_percentile": 57162.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52724.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 31908.47, "90th_percentile": 31908.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31908.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10434.11, "90th_percentile": 10434.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10434.11, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8411.42, "90th_percentile": 8411.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8411.42, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8426.43, "90th_percentile": 10843.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 10586.73, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25200.61, "90th_percentile": 25200.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25200.61, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10004.72, "90th_percentile": 10004.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10004.72, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7785.64, "90th_percentile": 8411.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7840.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9311.7, "90th_percentile": 9311.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9311.7, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23709.3, "90th_percentile": 23709.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23709.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5478.46, "90th_percentile": 9502.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9323.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8753.52, "90th_percentile": 10693.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 10664.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20668.67, "90th_percentile": 35309.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23410.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "390", "type": "MS-DRG" } ], "description": "Gastrointestinal Obstruction Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 12107.87, "minimum": 5435.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12107.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10822.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 11298.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10178.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9549.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5435.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10114.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8174.44, "90th_percentile": 12794.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12098.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3733.46, "90th_percentile": 4641.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4434.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10748.1, "90th_percentile": 10824.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10824.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5005.44, "90th_percentile": 5005.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5005.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7377.88, "90th_percentile": 7377.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7377.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4277.39, "90th_percentile": 4277.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4277.39, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4092.12, "90th_percentile": 4092.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4092.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19927.46, "90th_percentile": 19927.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19927.46, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 11300.23, "90th_percentile": 11300.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11300.23, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4103.34, "90th_percentile": 5328.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5278.95, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9170.43, "90th_percentile": 9170.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9170.43, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4201.01, "90th_percentile": 4201.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4201.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5053.49, "90th_percentile": 5053.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5053.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9550.83, "90th_percentile": 10100.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9550.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "389", "type": "MS-DRG" } ], "description": "Gastrointestinal Obstruction With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 17742.42, "minimum": 7344.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17742.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15859.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16555.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14915.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13992.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7344.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14821.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17723.38, "90th_percentile": 17723.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17723.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5292.11, "90th_percentile": 6949.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 6366.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6013.82, "90th_percentile": 6013.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6013.82, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10208.85, "90th_percentile": 15857.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13807.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5279.4, "90th_percentile": 6923.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5714.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8541.55, "90th_percentile": 8541.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8541.55, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5443.55, "90th_percentile": 8007.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5443.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6013.82, "90th_percentile": 6013.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6013.82, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4805.97, "90th_percentile": 7214.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5599.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14928.65, "90th_percentile": 14928.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14928.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 568.19, "90th_percentile": 568.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 568.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 590.48, "90th_percentile": 590.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 590.48, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6104.49, "90th_percentile": 6104.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6104.49, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13991.13, "90th_percentile": 14578.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13991.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5231.22, "90th_percentile": 7009.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 6735.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13991.13, "90th_percentile": 14795.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13991.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "388", "type": "MS-DRG" } ], "description": "Gastrointestinal Obstruction With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32532.57, "minimum": 12679.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32532.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29079.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30356.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27349.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25657.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12679.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27175.89 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 32530.36, "90th_percentile": 32530.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32530.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1041.91, "90th_percentile": 12316.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11263.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18480.8, "90th_percentile": 29007.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25581.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11984.64, "90th_percentile": 11984.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11984.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7245.06, "90th_percentile": 7245.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7245.06, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15777.14, "90th_percentile": 15777.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15777.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 27676.2, "90th_percentile": 27676.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27676.2, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11120.83, "90th_percentile": 12021.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11965.95, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28837.97, "90th_percentile": 28837.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28837.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 11988.78, "90th_percentile": 11988.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11988.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6013.82, "90th_percentile": 17429.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6013.82, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12402.91, "90th_percentile": 12402.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12402.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10197.59, "90th_percentile": 12108.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11668.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "387", "type": "MS-DRG" } ], "description": "Inflammatory Bowel Disease Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14834.41, "minimum": 6501.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14834.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13259.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13842.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12470.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11699.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6501.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12391.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15672.28, "90th_percentile": 15672.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15672.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6378.77, "90th_percentile": 6378.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6378.77, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12130.65, "90th_percentile": 14370.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13259.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5039.55, "90th_percentile": 5039.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5039.55, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4724.58, "90th_percentile": 4724.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4724.58, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26232.38, "90th_percentile": 26232.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26232.38, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 13327.28, "90th_percentile": 13327.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13327.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13150.62, "90th_percentile": 13150.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13150.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39246.43, "90th_percentile": 39246.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39246.43, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11597.05, "90th_percentile": 11597.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11597.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4949.56, "90th_percentile": 4949.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4949.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4236.07, "90th_percentile": 4236.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4236.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8939.42, "90th_percentile": 12372.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11469.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "386", "type": "MS-DRG" } ], "description": "Inflammatory Bowel Disease With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 21962.8, "minimum": 8792.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21962.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19631.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20494.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18463.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17321.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8792.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18346.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 56208.31, "90th_percentile": 56208.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56208.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7000.58, "90th_percentile": 8540.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8350.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16089.87, "90th_percentile": 19633.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 18836.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6478.66, "90th_percentile": 6565.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6478.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8619.8, "90th_percentile": 8619.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8619.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 10173.38, "90th_percentile": 10173.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10173.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8004.08, "90th_percentile": 8004.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8004.08, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6128.46, "90th_percentile": 6128.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6128.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9864.07, "90th_percentile": 9864.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9864.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8364.79, "90th_percentile": 8364.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8364.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12476.4, "90th_percentile": 41647.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18465.46, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6420.29, "90th_percentile": 6420.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6420.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7015.55, "90th_percentile": 8464.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7015.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14863.1, "90th_percentile": 18319.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17323.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "385", "type": "MS-DRG" } ], "description": "Inflammatory Bowel Disease With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35956.24, "minimum": 13498.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35956.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32139.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33551.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30227.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28357.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13498.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30035.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 27591.4, "90th_percentile": 27591.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27591.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11804.08, "90th_percentile": 11804.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11804.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2612.27, "90th_percentile": 2612.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2612.27, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27026.0, "90th_percentile": 31914.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29369.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13155.51, "90th_percentile": 13155.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13155.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8846.62, "90th_percentile": 8846.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8846.62, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11605.8, "90th_percentile": 11605.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11605.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 34391.29, "90th_percentile": 34391.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34391.29, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28359.26, "90th_percentile": 28359.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28359.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6420.29, "90th_percentile": 6420.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6420.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12942.73, "90th_percentile": 12942.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12942.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "384", "type": "MS-DRG" } ], "description": "Uncomplicated Peptic Ulcer Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19245.12, "minimum": 7848.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19245.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17202.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17958.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16178.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15178.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7848.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16076.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17824.29, "90th_percentile": 18043.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17824.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 15956.11, "90th_percentile": 15956.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15956.11, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6659.09, "90th_percentile": 7499.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6659.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5150.83, "90th_percentile": 5150.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5150.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15178.0, "90th_percentile": 15178.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15178.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "383", "type": "MS-DRG" } ], "description": "Uncomplicated Peptic Ulcer With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27978.01, "minimum": 11932.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27978.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25008.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26106.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23520.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22065.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11932.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23371.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10448.15, "90th_percentile": 10448.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10448.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14827.17, "90th_percentile": 14827.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14827.17, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29319.97, "90th_percentile": 29319.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29319.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "382", "type": "MS-DRG" } ], "description": "Complicated Peptic Ulcer Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16582.76, "minimum": 7427.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16582.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14822.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15473.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13940.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13078.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13852.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 531.12, "90th_percentile": 531.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 531.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14701.25, "90th_percentile": 14701.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14701.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6067.01, "90th_percentile": 6067.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6067.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 16286.04, "90th_percentile": 16286.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16286.04, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6117.32, "90th_percentile": 6117.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6117.32, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "381", "type": "MS-DRG" } ], "description": "Complicated Peptic Ulcer With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 24102.87, "minimum": 9624.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24102.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21544.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22491.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20262.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19009.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9624.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20134.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 24102.87, "90th_percentile": 24102.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24102.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9101.98, "90th_percentile": 9101.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9101.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6134.89, "90th_percentile": 6134.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6134.89, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18411.28, "90th_percentile": 18411.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18411.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7800.99, "90th_percentile": 8241.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7800.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5553.14, "90th_percentile": 5553.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5553.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19894.19, "90th_percentile": 19894.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19894.19, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7095.39, "90th_percentile": 7741.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7095.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 9126.6, "90th_percentile": 9126.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9126.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6702.6, "90th_percentile": 6702.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6702.6, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28013.8, "90th_percentile": 28013.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28013.8, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11127.89, "90th_percentile": 11127.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11127.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8991.82, "90th_percentile": 8991.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8991.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15259.68, "90th_percentile": 15259.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15259.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "380", "type": "MS-DRG" } ], "description": "Complicated Peptic Ulcer With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 42586.68, "minimum": 16448.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42586.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38066.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39738.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35801.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33586.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16448.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35574.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14575.33, "90th_percentile": 14575.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14575.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 16060.21, "90th_percentile": 16060.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16060.21, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15392.87, "90th_percentile": 15392.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15392.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7798.77, "90th_percentile": 7798.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7798.77, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13236.87, "90th_percentile": 13236.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13236.87, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37752.84, "90th_percentile": 37752.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37752.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 21375.66, "90th_percentile": 21375.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21375.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15407.39, "90th_percentile": 15533.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15523.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "379", "type": "MS-DRG" } ], "description": "Gastrointestinal Hemorrhage Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14088.59, "minimum": 6106.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14088.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12593.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13146.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11843.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11111.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6106.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11768.82 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5687.44, "90th_percentile": 5687.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5687.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6652.69, "90th_percentile": 6652.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6652.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12595.2, "90th_percentile": 12595.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12595.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4412.12, "90th_percentile": 4412.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4412.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5688.26, "90th_percentile": 5688.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5688.26, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5431.97, "90th_percentile": 5431.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5431.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "378", "type": "MS-DRG" } ], "description": "Gastrointestinal Hemorrhage With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 21818.95, "minimum": 8826.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21818.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19503.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20359.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18342.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17207.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8826.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18226.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22929.75, "90th_percentile": 22929.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22929.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6239.86, "90th_percentile": 8327.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 7623.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 8472.6, "90th_percentile": 8472.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8472.6, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5806.87, "90th_percentile": 5806.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5806.87, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16057.26, "90th_percentile": 19503.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 19060.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5137.02, "90th_percentile": 5137.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5137.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6526.69, "90th_percentile": 8336.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 7635.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 20351.14, "90th_percentile": 20351.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20351.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5336.98, "90th_percentile": 5336.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5336.98, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9595.81, "90th_percentile": 17622.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9595.81, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5256.22, "90th_percentile": 6021.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5486.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6746.16, "90th_percentile": 6746.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6746.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 18925.69, "90th_percentile": 18925.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18925.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7271.44, "90th_percentile": 7271.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7271.44, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8615.78, "90th_percentile": 8615.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8615.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6196.95, "90th_percentile": 8378.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 7751.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19240.35, "90th_percentile": 25486.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19342.37, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 21215.43, "90th_percentile": 21215.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21215.43, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 6828.05, "90th_percentile": 8573.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7175.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8323.42, "90th_percentile": 8325.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8323.42, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5806.87, "90th_percentile": 8525.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6134.89, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6978.01, "90th_percentile": 6978.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6978.01, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8491.58, "90th_percentile": 18072.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8491.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8084.16, "90th_percentile": 8084.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8084.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6284.98, "90th_percentile": 8652.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 8390.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12121.13, "90th_percentile": 18197.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17207.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "377", "type": "MS-DRG" } ], "description": "Gastrointestinal Hemorrhage With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40236.37, "minimum": 15406.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40236.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35965.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37545.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33825.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31733.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15406.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33611.21 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 42511.33, "90th_percentile": 42511.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42511.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1307.73, "90th_percentile": 14692.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 13297.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 26736.2, "90th_percentile": 26736.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26736.2, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15448.76, "90th_percentile": 15448.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15448.76, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35713.08, "90th_percentile": 38117.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37660.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8157.66, "90th_percentile": 8157.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8157.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13067.54, "90th_percentile": 14963.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 14085.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 9105.43, "90th_percentile": 33675.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9758.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 14916.05, "90th_percentile": 14916.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14916.05, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28565.95, "90th_percentile": 28565.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28565.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5553.14, "90th_percentile": 8676.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7716.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13460.66, "90th_percentile": 13460.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13460.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 75485.61, "90th_percentile": 75485.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75485.61, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 12764.4, "90th_percentile": 14864.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12764.4, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6632.21, "90th_percentile": 6632.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6632.21, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8525.12, "90th_percentile": 8525.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8525.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11819.79, "90th_percentile": 14675.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 13842.82, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28951.25, "90th_percentile": 28951.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28951.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 14115.08, "90th_percentile": 41176.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14115.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13297.98, "90th_percentile": 14691.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14592.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13993.77, "90th_percentile": 16820.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16220.16, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5924.41, "90th_percentile": 19609.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8491.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13870.42, "90th_percentile": 15166.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13870.42, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7382.94, "90th_percentile": 8170.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8138.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12759.49, "90th_percentile": 15103.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 14725.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33560.34, "90th_percentile": 145225.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33560.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "376", "type": "MS-DRG" } ], "description": "Digestive Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19539.46, "minimum": 8388.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19539.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17465.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18232.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16426.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15410.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8388.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16322.17 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6628.38, "90th_percentile": 6628.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6628.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11992.65, "90th_percentile": 11992.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11992.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17060.73, "90th_percentile": 17060.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17060.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "375", "type": "MS-DRG" } ], "description": "Digestive Malignancy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 27192.36, "minimum": 10604.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27192.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24306.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25373.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22859.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21445.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10604.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22714.98 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9009.01, "90th_percentile": 9283.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9276.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27166.56, "90th_percentile": 27166.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27166.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24920.18, "90th_percentile": 24920.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24920.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7260.62, "90th_percentile": 7260.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7260.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8959.76, "90th_percentile": 9675.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9483.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2666.14, "90th_percentile": 2666.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2666.14, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6092.15, "90th_percentile": 6092.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6092.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 26705.79, "90th_percentile": 26705.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26705.79, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8240.11, "90th_percentile": 9920.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9043.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29013.0, "90th_percentile": 29013.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29013.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10168.79, "90th_percentile": 10168.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10168.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21445.73, "90th_percentile": 21445.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21445.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7195.21, "90th_percentile": 7195.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7195.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10553.44, "90th_percentile": 10553.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10553.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21445.73, "90th_percentile": 22679.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22679.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "374", "type": "MS-DRG" } ], "description": "Digestive Malignancy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 46729.61, "minimum": 17819.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46729.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41769.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43604.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39284.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36854.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17819.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39035.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15632.16, "90th_percentile": 17323.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16805.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7587.68, "90th_percentile": 7587.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7587.68, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39872.8, "90th_percentile": 41767.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41472.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 17047.38, "90th_percentile": 17047.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17047.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13854.58, "90th_percentile": 16852.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16803.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 15618.59, "90th_percentile": 15618.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15618.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34478.35, "90th_percentile": 34478.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34478.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15792.02, "90th_percentile": 15792.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15792.02, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14836.57, "90th_percentile": 16918.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16803.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37781.7, "90th_percentile": 41423.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37781.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15526.91, "90th_percentile": 15526.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15526.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17815.28, "90th_percentile": 17815.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17815.28, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 17463.39, "90th_percentile": 17463.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17463.39, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39476.12, "90th_percentile": 39476.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39476.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13983.08, "90th_percentile": 16970.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15195.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38263.94, "90th_percentile": 38263.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38263.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "373", "type": "MS-DRG" } ], "description": "Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16051.61, "minimum": 6859.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16051.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14347.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14978.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13494.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12659.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6859.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13408.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16960.58, "90th_percentile": 16960.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16960.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13278.6, "90th_percentile": 14349.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14248.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6224.26, "90th_percentile": 6224.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6224.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 6871.02, "90th_percentile": 6871.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6871.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4031.8, "90th_percentile": 4031.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4031.8, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9228.4, "90th_percentile": 14231.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9228.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 5596.43, "90th_percentile": 5596.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5596.43, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4938.45, "90th_percentile": 4938.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4938.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5058.81, "90th_percentile": 5058.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5058.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5165.22, "90th_percentile": 5165.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5165.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12661.13, "90th_percentile": 12661.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12661.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "372", "type": "MS-DRG" } ], "description": "Major Gastrointestinal Disorders And Peritoneal Infections With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22779.44, "minimum": 9139.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22779.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20361.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21256.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19150.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17965.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9139.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19028.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 11544.8, "90th_percentile": 24066.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17051.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7175.12, "90th_percentile": 8649.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 7920.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19485.38, "90th_percentile": 20629.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19485.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9732.13, "90th_percentile": 20217.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18395.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6224.26, "90th_percentile": 6224.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6224.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8877.83, "90th_percentile": 8984.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8877.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 17281.73, "90th_percentile": 17281.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17281.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5887.81, "90th_percentile": 5887.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5887.81, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 22371.84, "90th_percentile": 22371.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22371.84, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8090.28, "90th_percentile": 8090.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8090.28, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6385.54, "90th_percentile": 8666.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6913.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18697.51, "90th_percentile": 19301.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18697.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7927.61, "90th_percentile": 7927.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7927.61, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 758.21, "90th_percentile": 758.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 758.21, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5013.71, "90th_percentile": 5013.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5013.71, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17965.4, "90th_percentile": 18320.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17965.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9136.02, "90th_percentile": 9136.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9136.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6811.24, "90th_percentile": 13910.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8730.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2466.0, "90th_percentile": 2466.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2466.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "371", "type": "MS-DRG" } ], "description": "Major Gastrointestinal Disorders And Peritoneal Infections With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38691.63, "minimum": 14980.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38691.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34584.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36104.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32527.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30514.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14980.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32320.82 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12120.4, "90th_percentile": 14095.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 13251.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 15223.22, "90th_percentile": 15223.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15223.22, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30952.75, "90th_percentile": 36529.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33354.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9305.83, "90th_percentile": 9305.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9305.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12420.8, "90th_percentile": 14686.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14054.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 12354.45, "90th_percentile": 12354.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12354.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 25481.72, "90th_percentile": 25481.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25481.72, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22982.35, "90th_percentile": 22982.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22982.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8592.83, "90th_percentile": 27944.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12859.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9634.35, "90th_percentile": 9634.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9634.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11464.75, "90th_percentile": 14157.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 12462.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34294.01, "90th_percentile": 259435.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34294.01, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14552.32, "90th_percentile": 14552.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14552.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6504.63, "90th_percentile": 6504.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6504.63, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14615.84, "90th_percentile": 14615.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14615.84, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32727.88, "90th_percentile": 32727.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32727.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14165.48, "90th_percentile": 14216.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14165.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30509.59, "90th_percentile": 30509.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30509.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "370", "type": "MS-DRG" } ], "description": "Major Esophageal Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15445.22, "minimum": 6652.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15445.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13805.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14412.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12984.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12181.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6652.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12902.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "369", "type": "MS-DRG" } ], "description": "Major Esophageal Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22520.51, "minimum": 8977.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22520.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20130.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21014.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18932.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17761.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8977.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18812.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8597.01, "90th_percentile": 8597.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8597.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23425.93, "90th_percentile": 23425.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23425.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5623.22, "90th_percentile": 5623.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5623.22, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8899.93, "90th_percentile": 8899.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8899.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7411.96, "90th_percentile": 8738.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7411.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7414.65, "90th_percentile": 7414.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7414.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "368", "type": "MS-DRG" } ], "description": "Major Esophageal Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36956.56, "minimum": 13573.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36956.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33033.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34485.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31068.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29146.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13573.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30871.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12769.9, "90th_percentile": 13181.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12769.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7650.85, "90th_percentile": 7650.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7650.85, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33035.94, "90th_percentile": 33035.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33035.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12046.38, "90th_percentile": 12046.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12046.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 32802.14, "90th_percentile": 32802.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32802.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5563.45, "90th_percentile": 5563.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5563.45, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6067.01, "90th_percentile": 13909.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8899.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6702.6, "90th_percentile": 6702.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6702.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13465.23, "90th_percentile": 13465.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13465.23, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32763.73, "90th_percentile": 32763.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32763.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8116.11, "90th_percentile": 8116.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8116.11, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7696.32, "90th_percentile": 7696.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7696.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11916.34, "90th_percentile": 13281.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11916.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "358", "type": "MS-DRG" } ], "description": "Other Digestive System O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29987.51, "minimum": 12066.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29987.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26804.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27982.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25209.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23650.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12066.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25049.89 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 32684.3, "90th_percentile": 32684.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32684.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29149.01, "90th_percentile": 29149.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29149.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7709.14, "90th_percentile": 7709.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7709.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11100.21, "90th_percentile": 11100.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11100.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7374.5, "90th_percentile": 7374.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7374.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11118.58, "90th_percentile": 11118.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11118.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8147.06, "90th_percentile": 8147.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8147.06, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24683.89, "90th_percentile": 24683.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24683.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10020.94, "90th_percentile": 10020.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10020.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23651.92, "90th_percentile": 23651.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23651.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "357", "type": "MS-DRG" } ], "description": "Other Digestive System O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 49836.8, "minimum": 19270.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49836.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44547.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46503.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41896.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39304.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19270.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41630.88 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 51505.32, "90th_percentile": 51505.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51505.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16275.74, "90th_percentile": 22881.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16283.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40529.33, "90th_percentile": 47909.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42521.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10464.43, "90th_percentile": 10464.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10464.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17889.06, "90th_percentile": 18720.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17915.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46958.7, "90th_percentile": 46958.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46958.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 22615.69, "90th_percentile": 22615.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22615.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 9147.68, "90th_percentile": 10558.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9147.68, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8696.56, "90th_percentile": 9898.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9397.51, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 86229.82, "90th_percentile": 86229.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 86229.82, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17138.92, "90th_percentile": 18720.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17915.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17986.36, "90th_percentile": 17986.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17986.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8861.97, "90th_percentile": 8861.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8861.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39306.41, "90th_percentile": 41567.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39306.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9721.67, "90th_percentile": 9721.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9721.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17856.75, "90th_percentile": 18890.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18027.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38095.89, "90th_percentile": 220036.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41567.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "356", "type": "MS-DRG" } ], "description": "Other Digestive System O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 94397.57, "minimum": 35324.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94397.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 84378.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 88084.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79357.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74448.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35324.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78854.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 200723.9, "90th_percentile": 200723.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 200723.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21954.14, "90th_percentile": 33169.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32732.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 26891.31, "90th_percentile": 26891.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26891.31, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 81810.85, "90th_percentile": 264844.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83786.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 34331.97, "90th_percentile": 34331.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34331.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20214.02, "90th_percentile": 39511.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31175.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 14492.3, "90th_percentile": 14492.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14492.3, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 22273.66, "90th_percentile": 22273.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22273.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 148531.78, "90th_percentile": 148531.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 148531.78, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 32060.51, "90th_percentile": 32060.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32060.51, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 17268.03, "90th_percentile": 17268.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17268.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30894.84, "90th_percentile": 34632.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31406.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 84209.5, "90th_percentile": 105001.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 86182.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 43302.32, "90th_percentile": 43302.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43302.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 33183.59, "90th_percentile": 36616.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33351.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 33066.28, "90th_percentile": 33066.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33066.28, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38831.61, "90th_percentile": 38831.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38831.61, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13937.04, "90th_percentile": 13937.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13937.04, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 32640.98, "90th_percentile": 32640.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32640.98, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 78060.97, "90th_percentile": 198338.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78060.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28072.85, "90th_percentile": 34666.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32766.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 76122.69, "90th_percentile": 197739.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79306.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "355", "type": "MS-DRG" } ], "description": "Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29502.84, "minimum": 11655.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29502.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26371.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27529.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24802.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23267.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11655.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24645.02 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29741.13, "90th_percentile": 29741.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29741.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11128.18, "90th_percentile": 11128.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11128.18, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27799.89, "90th_percentile": 27799.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27799.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 27921.24, "90th_percentile": 27921.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27921.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8348.18, "90th_percentile": 8348.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8348.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 962.2, "90th_percentile": 962.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 962.2, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10528.76, "90th_percentile": 10528.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10528.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25867.86, "90th_percentile": 25867.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25867.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10690.98, "90th_percentile": 10690.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10690.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "354", "type": "MS-DRG" } ], "description": "Hernia Procedures Except Inguinal And Femoral With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 37647.04, "minimum": 14275.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37647.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33651.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35129.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31648.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29691.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14275.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31448.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12510.81, "90th_percentile": 12510.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12510.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 12503.39, "90th_percentile": 12503.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12503.39, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33273.47, "90th_percentile": 34660.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33273.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13196.97, "90th_percentile": 13875.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13420.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 51691.44, "90th_percentile": 51691.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51691.44, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12260.43, "90th_percentile": 12260.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12260.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29691.0, "90th_percentile": 29691.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29691.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12071.81, "90th_percentile": 14123.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12653.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39654.36, "90th_percentile": 39654.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39654.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "353", "type": "MS-DRG" } ], "description": "Hernia Procedures Except Inguinal And Femoral With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 64905.8, "minimum": 23746.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64905.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 58016.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 60565.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54564.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51189.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23746.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 54218.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23045.79, "90th_percentile": 23045.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23045.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 58020.61, "90th_percentile": 58020.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58020.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23159.1, "90th_percentile": 23159.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23159.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23209.33, "90th_percentile": 23209.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23209.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "352", "type": "MS-DRG" } ], "description": "Inguinal And Femoral Hernia Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24399.43, "minimum": 10279.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24399.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21809.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22767.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20512.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19243.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10279.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20381.92 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7553.61, "90th_percentile": 7553.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7553.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21657.27, "90th_percentile": 21657.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21657.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7553.44, "90th_percentile": 7553.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7553.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7597.5, "90th_percentile": 7597.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7597.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "351", "type": "MS-DRG" } ], "description": "Inguinal And Femoral Hernia Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 33300.52, "minimum": 13049.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33300.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29765.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31073.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27994.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26263.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13049.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27817.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12258.01, "90th_percentile": 12258.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12258.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31407.75, "90th_percentile": 31407.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31407.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12137.91, "90th_percentile": 12137.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12137.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6948.18, "90th_percentile": 6948.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6948.18, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7597.5, "90th_percentile": 7597.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7597.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 3351.4, "90th_percentile": 3351.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3351.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27070.69, "90th_percentile": 27070.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27070.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "350", "type": "MS-DRG" } ], "description": "Inguinal And Femoral Hernia Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 53552.59, "minimum": 20562.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53552.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 47868.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 49971.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45020.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42235.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20562.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44734.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1782.69, "90th_percentile": 1782.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1782.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "349", "type": "MS-DRG" } ], "description": "Anal And Stomal Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19495.2, "minimum": 7971.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19495.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17425.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18191.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16389.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15375.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7971.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16285.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "348", "type": "MS-DRG" } ], "description": "Anal And Stomal Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 27858.5, "minimum": 11374.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27858.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24901.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25995.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23419.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21971.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11374.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23271.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10116.95, "90th_percentile": 10116.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10116.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17307.68, "90th_percentile": 18694.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17307.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 15666.98, "90th_percentile": 15666.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15666.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 16957.35, "90th_percentile": 16957.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16957.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7246.49, "90th_percentile": 7246.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7246.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7274.44, "90th_percentile": 7274.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7274.44, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7459.73, "90th_percentile": 7459.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7459.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9891.29, "90th_percentile": 9891.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9891.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "347", "type": "MS-DRG" } ], "description": "Anal And Stomal Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 52375.22, "minimum": 19037.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52375.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46816.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 48872.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44030.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41306.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19037.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43751.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16583.53, "90th_percentile": 16583.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16583.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46581.55, "90th_percentile": 46581.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46581.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18730.04, "90th_percentile": 18730.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18730.04, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "346", "type": "MS-DRG" } ], "description": "Minor Small And Large Bowel Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27557.52, "minimum": 10422.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27557.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24632.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25714.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23166.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21733.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10422.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23020.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16776.99, "90th_percentile": 25717.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16776.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7391.65, "90th_percentile": 7391.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7391.65, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 27066.6, "90th_percentile": 27066.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27066.6, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12239.71, "90th_percentile": 12239.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12239.71, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22715.75, "90th_percentile": 22715.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22715.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "345", "type": "MS-DRG" } ], "description": "Minor Small And Large Bowel Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 32957.49, "minimum": 12895.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32957.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29459.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30753.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27706.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25992.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12895.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27530.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12527.3, "90th_percentile": 12527.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12527.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29241.05, "90th_percentile": 29241.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29241.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11079.04, "90th_percentile": 11079.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11079.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7866.62, "90th_percentile": 7866.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7866.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12642.97, "90th_percentile": 12642.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12642.97, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12126.62, "90th_percentile": 12126.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12126.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25983.77, "90th_percentile": 25983.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25983.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "344", "type": "MS-DRG" } ], "description": "Minor Small And Large Bowel Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 59629.77, "minimum": 21268.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59629.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53300.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 55642.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50129.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47028.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21268.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49811.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21192.23, "90th_percentile": 21192.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21192.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 52925.37, "90th_percentile": 52925.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52925.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 47029.8, "90th_percentile": 47029.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47029.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "337", "type": "MS-DRG" } ], "description": "Peritoneal Adhesiolysis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33971.09, "minimum": 13131.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33971.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30365.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31699.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28558.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26791.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13131.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28377.55 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12461.78, "90th_percentile": 12465.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12461.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33941.06, "90th_percentile": 33941.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33941.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30152.43, "90th_percentile": 32009.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30152.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12197.31, "90th_percentile": 12197.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12197.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 37994.06, "90th_percentile": 37994.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37994.06, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11847.07, "90th_percentile": 11847.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11847.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12305.11, "90th_percentile": 12305.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12305.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9165.5, "90th_percentile": 9165.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9165.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11276.77, "90th_percentile": 12566.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11276.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26793.64, "90th_percentile": 28333.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26793.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "336", "type": "MS-DRG" } ], "description": "Peritoneal Adhesiolysis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 46749.52, "minimum": 17586.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46749.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41787.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43623.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39301.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36869.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17586.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39051.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15168.39, "90th_percentile": 15168.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15168.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38495.58, "90th_percentile": 43443.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 41785.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 11423.18, "90th_percentile": 11423.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11423.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16438.99, "90th_percentile": 16438.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16438.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 34210.06, "90th_percentile": 34210.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34210.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4852.08, "90th_percentile": 4852.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4852.08, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3117.82, "90th_percentile": 3117.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3117.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 106845.76, "90th_percentile": 106845.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 106845.76, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15089.71, "90th_percentile": 16896.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16094.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38444.93, "90th_percentile": 38444.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38444.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17084.39, "90th_percentile": 17084.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17084.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15871.64, "90th_percentile": 15871.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15871.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41442.66, "90th_percentile": 41442.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41442.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15298.72, "90th_percentile": 15371.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15298.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35291.52, "90th_percentile": 38988.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38867.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "335", "type": "MS-DRG" } ], "description": "Peritoneal Adhesiolysis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 80200.53, "minimum": 28941.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80200.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 71687.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 74837.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67422.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63251.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28941.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66995.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28142.51, "90th_percentile": 28249.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28245.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 73567.68, "90th_percentile": 413143.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73567.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26276.47, "90th_percentile": 28408.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28206.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16465.02, "90th_percentile": 16465.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16465.02, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9665.43, "90th_percentile": 9665.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9665.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26233.41, "90th_percentile": 28206.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26452.21, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 277215.83, "90th_percentile": 277215.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 277215.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 27450.36, "90th_percentile": 27450.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27450.36, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26234.46, "90th_percentile": 36824.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26539.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "334", "type": "MS-DRG" } ], "description": "Rectal Resection Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36702.05, "minimum": 13930.22, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36702.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32806.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34247.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30854.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28945.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13930.22 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30658.84 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10595.54, "90th_percentile": 10595.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10595.54, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32540.07, "90th_percentile": 32540.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32540.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "333", "type": "MS-DRG" } ], "description": "Rectal Resection With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 47030.59, "minimum": 19399.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47030.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42038.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43885.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39537.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37091.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19399.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39286.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36776.44, "90th_percentile": 36776.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36776.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22043.14, "90th_percentile": 22043.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22043.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43232.33, "90th_percentile": 43232.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43232.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "332", "type": "MS-DRG" } ], "description": "Rectal Resection With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 76761.37, "minimum": 29328.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76761.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 68613.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 71627.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64531.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60539.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29328.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64122.16 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "331", "type": "MS-DRG" } ], "description": "Major Small And Large Bowel Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36538.28, "minimum": 14279.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36538.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32660.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34094.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30716.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28816.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14279.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30522.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 36503.61, "90th_percentile": 39347.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 38602.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11689.44, "90th_percentile": 13867.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 13331.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36248.85, "90th_percentile": 36248.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36248.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 11613.39, "90th_percentile": 11613.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11613.39, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31876.27, "90th_percentile": 35091.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "47", "median_amount": 32660.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13592.18, "90th_percentile": 13592.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13592.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12217.43, "90th_percentile": 13568.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 12767.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 23193.09, "90th_percentile": 54472.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33779.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10124.31, "90th_percentile": 10124.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10124.31, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18071.17, "90th_percentile": 18071.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18071.17, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9573.61, "90th_percentile": 9573.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9573.61, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 56409.98, "90th_percentile": 56409.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56409.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 36577.83, "90th_percentile": 91615.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37264.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 36577.83, "90th_percentile": 36577.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36577.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13705.33, "90th_percentile": 13705.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13705.33, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 14216.02, "90th_percentile": 14216.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14216.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13340.95, "90th_percentile": 13879.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13369.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31832.58, "90th_percentile": 32390.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 32390.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13213.47, "90th_percentile": 13213.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13213.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10485.89, "90th_percentile": 14113.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10485.89, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28816.55, "90th_percentile": 45284.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28816.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13383.76, "90th_percentile": 13383.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13383.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13453.37, "90th_percentile": 13543.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13458.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27504.39, "90th_percentile": 32923.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 28816.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "330", "type": "MS-DRG" } ], "description": "Major Small And Large Bowel Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 52311.04, "minimum": 19826.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52311.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46758.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 48812.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43976.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41256.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19826.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43697.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 52261.41, "90th_percentile": 57120.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54265.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17037.05, "90th_percentile": 19144.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 18651.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 55265.67, "90th_percentile": 55265.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55265.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14113.78, "90th_percentile": 14113.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14113.78, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41785.49, "90th_percentile": 49387.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 46427.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13603.26, "90th_percentile": 13603.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13603.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16330.96, "90th_percentile": 19261.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 18494.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 33871.15, "90th_percentile": 71787.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42244.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 168585.59, "90th_percentile": 168585.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 168585.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12775.4, "90th_percentile": 20013.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16862.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 120294.21, "90th_percentile": 151364.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 120294.21, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 49983.35, "90th_percentile": 264599.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51375.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 207656.68, "90th_percentile": 207656.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 207656.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15179.83, "90th_percentile": 33885.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19046.02, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 14216.02, "90th_percentile": 18629.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14216.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17478.34, "90th_percentile": 23899.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 18736.06, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43976.64, "90th_percentile": 46373.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 46373.43, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 28057.83, "90th_percentile": 39454.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28057.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17540.01, "90th_percentile": 19438.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17957.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14216.02, "90th_percentile": 14306.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14216.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 139114.61, "90th_percentile": 139114.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 139114.61, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41161.08, "90th_percentile": 216892.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44247.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13383.76, "90th_percentile": 13383.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13383.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17122.77, "90th_percentile": 19005.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 18658.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41188.21, "90th_percentile": 45284.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 42525.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "329", "type": "MS-DRG" } ], "description": "Major Small And Large Bowel Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 101618.91, "minimum": 36906.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101618.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 90833.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 94823.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85428.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80143.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36906.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 84886.76 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 96809.0, "90th_percentile": 114291.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 101526.91, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27665.52, "90th_percentile": 35867.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 32588.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 34376.54, "90th_percentile": 34376.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34376.54, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22110.66, "90th_percentile": 22110.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22110.66, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 65143.85, "90th_percentile": 291489.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 90836.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13603.26, "90th_percentile": 41214.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21157.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24010.52, "90th_percentile": 36183.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 33346.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 44231.86, "90th_percentile": 152774.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108539.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 17986.81, "90th_percentile": 17986.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17986.81, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74572.39, "90th_percentile": 74572.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74572.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8737.61, "90th_percentile": 16862.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9945.33, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34191.01, "90th_percentile": 34191.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34191.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 111887.79, "90th_percentile": 249279.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 111887.79, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 36519.13, "90th_percentile": 36519.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36519.13, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 22201.32, "90th_percentile": 66633.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30575.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24994.73, "90th_percentile": 49191.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 33828.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 88410.46, "90th_percentile": 259909.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 175289.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 35854.54, "90th_percentile": 36175.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35854.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15011.13, "90th_percentile": 15011.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15011.13, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36834.69, "90th_percentile": 36834.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36834.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 194158.0, "90th_percentile": 194158.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 194158.0, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 84757.29, "90th_percentile": 245723.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 209134.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 20967.0, "90th_percentile": 49109.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20967.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34634.61, "90th_percentile": 36701.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 35834.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 80147.2, "90th_percentile": 84842.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84842.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "328", "type": "MS-DRG" } ], "description": "Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35263.54, "minimum": 13653.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35263.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31520.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32905.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29645.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27811.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13653.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29457.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11768.45, "90th_percentile": 17600.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12913.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30645.8, "90th_percentile": 33411.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30645.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10854.25, "90th_percentile": 10854.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10854.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11959.07, "90th_percentile": 13417.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12898.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10267.53, "90th_percentile": 10349.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10267.53, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 11705.77, "90th_percentile": 11705.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11705.77, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12957.11, "90th_percentile": 13395.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12957.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31435.52, "90th_percentile": 31435.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31435.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6232.41, "90th_percentile": 11433.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6232.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27812.95, "90th_percentile": 27812.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27812.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10756.46, "90th_percentile": 10756.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10756.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13052.03, "90th_percentile": 13084.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13052.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29412.82, "90th_percentile": 29575.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29412.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "327", "type": "MS-DRG" } ], "description": "Stomach, Esophageal And Duodenal Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 53736.28, "minimum": 20191.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53736.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48032.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 50142.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45174.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42380.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20191.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 44888.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17464.94, "90th_percentile": 19518.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18443.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 45987.48, "90th_percentile": 50966.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 47692.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17673.34, "90th_percentile": 19356.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19216.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 33260.8, "90th_percentile": 33260.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33260.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20155.11, "90th_percentile": 20155.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20155.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 99381.2, "90th_percentile": 99381.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99381.2, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15727.98, "90th_percentile": 15727.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15727.98, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17544.09, "90th_percentile": 56707.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19220.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 47636.89, "90th_percentile": 47636.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47636.89, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 19622.3, "90th_percentile": 19622.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19622.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11343.18, "90th_percentile": 11343.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11343.18, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 47860.06, "90th_percentile": 47860.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47860.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13887.96, "90th_percentile": 14147.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13887.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1982.28, "90th_percentile": 19367.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 18494.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42380.6, "90th_percentile": 45349.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44817.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "326", "type": "MS-DRG" } ], "description": "Stomach, Esophageal And Duodenal Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 112396.71, "minimum": 39941.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112396.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 100466.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 104880.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94489.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88643.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39941.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93889.93 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24111.75, "90th_percentile": 51623.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 38107.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 86173.58, "90th_percentile": 99761.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99761.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 14715.56, "90th_percentile": 23035.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14715.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24775.4, "90th_percentile": 39337.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26544.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 15869.86, "90th_percentile": 15869.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15869.86, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 18333.64, "90th_percentile": 21708.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18415.71, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 37785.86, "90th_percentile": 37785.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37785.86, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 24072.92, "90th_percentile": 47390.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30415.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36662.52, "90th_percentile": 63456.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37224.47, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 99644.9, "90th_percentile": 99644.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99644.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 71088.12, "90th_percentile": 71088.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71088.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 37566.86, "90th_percentile": 37566.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37566.86, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 99012.29, "90th_percentile": 99012.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99012.29, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 56178.74, "90th_percentile": 56178.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56178.74, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 44939.24, "90th_percentile": 44939.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44939.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37768.68, "90th_percentile": 39655.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38052.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 212496.84, "90th_percentile": 212496.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 212496.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "325", "type": "MS-DRG" } ], "description": "Coronary Intravascular Lithotripsy Without Intraluminal Device", "standard_charges": [ { "billing_class": "facility", "maximum": 63338.92, "minimum": 26141.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63338.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 56616.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 59103.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53247.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49953.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26141.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52909.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22465.59, "90th_percentile": 22465.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22465.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22536.3, "90th_percentile": 22536.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22536.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 21582.67, "90th_percentile": 21582.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21582.67, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "324", "type": "MS-DRG" } ], "description": "Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 70708.55, "minimum": 25680.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70708.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63203.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 65979.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59442.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55765.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25680.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59065.97 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22725.17, "90th_percentile": 25341.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24983.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63083.94, "90th_percentile": 63205.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63205.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25177.64, "90th_percentile": 25177.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25177.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10625.16, "90th_percentile": 10625.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10625.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23162.46, "90th_percentile": 25177.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24976.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 72660.16, "90th_percentile": 72660.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72660.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 24983.77, "90th_percentile": 24983.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24983.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11738.27, "90th_percentile": 11738.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11738.27, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 60228.69, "90th_percentile": 60228.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60228.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23733.89, "90th_percentile": 23733.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23733.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 59461.81, "90th_percentile": 59461.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59461.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "323", "type": "MS-DRG" } ], "description": "Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 94260.36, "minimum": 34816.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94260.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 84255.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 87956.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79242.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74340.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34816.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78739.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 85463.8, "90th_percentile": 85463.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85463.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28852.42, "90th_percentile": 33008.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30015.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90234.94, "90th_percentile": 90234.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90234.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32001.39, "90th_percentile": 33630.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32425.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 53118.52, "90th_percentile": 53118.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53118.52, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33303.17, "90th_percentile": 33303.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33303.17, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31324.52, "90th_percentile": 42779.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32988.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 96829.2, "90th_percentile": 96829.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 96829.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 30091.4, "90th_percentile": 30091.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30091.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 3137.57, "90th_percentile": 3137.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3137.57, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14216.84, "90th_percentile": 14216.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14216.84, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33288.26, "90th_percentile": 33321.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33303.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 89325.36, "90th_percentile": 89325.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 89325.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "322", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40037.19, "minimum": 14901.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40037.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35787.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37359.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33658.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31576.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14901.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33444.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 35715.92, "90th_percentile": 48585.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 41450.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12585.3, "90th_percentile": 14535.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 14424.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32615.14, "90th_percentile": 37725.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 35536.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9659.93, "90th_percentile": 9659.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9659.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12882.41, "90th_percentile": 14597.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 14221.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 19902.02, "90th_percentile": 19902.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19902.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8707.5, "90th_percentile": 13636.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8707.5, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23728.48, "90th_percentile": 23728.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23728.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9624.08, "90th_percentile": 10729.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9624.08, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 56891.27, "90th_percentile": 75731.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63094.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 55238.35, "90th_percentile": 62622.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55238.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 40042.21, "90th_percentile": 40042.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40042.21, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13936.0, "90th_percentile": 13936.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13936.0, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13248.33, "90th_percentile": 14543.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 14515.75, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34329.02, "90th_percentile": 46882.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35963.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13291.21, "90th_percentile": 15266.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13972.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 14007.48, "90th_percentile": 14007.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14007.48, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11738.27, "90th_percentile": 11738.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11738.27, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 82957.64, "90th_percentile": 82957.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82957.64, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31236.39, "90th_percentile": 35495.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32261.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13481.49, "90th_percentile": 13481.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13481.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12746.25, "90th_percentile": 14664.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 13893.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32007.44, "90th_percentile": 34116.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 32944.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "321", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal", "standard_charges": [ { "billing_class": "facility", "maximum": 63000.32, "minimum": 22339.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63000.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 56313.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 58787.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52962.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49686.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22339.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52626.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 64353.95, "90th_percentile": 100123.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65765.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19519.02, "90th_percentile": 22415.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 20736.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 63829.05, "90th_percentile": 63829.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63829.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 23245.8, "90th_percentile": 23245.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23245.8, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50955.65, "90th_percentile": 58846.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 55251.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13514.82, "90th_percentile": 13514.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13514.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20414.54, "90th_percentile": 22374.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 21761.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 14607.4, "90th_percentile": 14607.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14607.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 15042.97, "90th_percentile": 15042.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15042.97, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15917.76, "90th_percentile": 15917.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15917.76, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9055.7, "90th_percentile": 12868.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12868.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 49975.0, "90th_percentile": 49975.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49975.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 58121.67, "90th_percentile": 58121.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58121.67, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 22150.57, "90th_percentile": 22150.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22150.57, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20376.69, "90th_percentile": 22414.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 21517.04, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 54302.41, "90th_percentile": 57974.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55310.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 35091.25, "90th_percentile": 35091.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35091.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 18739.64, "90th_percentile": 21715.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20684.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14216.84, "90th_percentile": 47827.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14216.84, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21163.58, "90th_percentile": 21163.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21163.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 82378.5, "90th_percentile": 82378.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82378.5, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 51738.7, "90th_percentile": 51738.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51738.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21059.85, "90th_percentile": 45002.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22202.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50371.6, "90th_percentile": 50371.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50371.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "320", "type": "MS-DRG" } ], "description": "Other Endovascular Cardiac Valve Procedures Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 51224.41, "minimum": 19889.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51224.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45787.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47798.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43063.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40399.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19889.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42790.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16188.54, "90th_percentile": 16188.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16188.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "319", "type": "MS-DRG" } ], "description": "Other Endovascular Cardiac Valve Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 97210.42, "minimum": 35868.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 97210.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 86892.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 90709.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81722.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76666.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35868.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81204.15 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31867.8, "90th_percentile": 31867.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31867.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 32642.57, "90th_percentile": 32642.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32642.57, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "317", "type": "MS-DRG" } ], "description": "Concomitant Left Atrial Appendage Closure And Cardiac Ablation", "standard_charges": [ { "billing_class": "facility", "maximum": 136902.37, "minimum": 53136.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 136902.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 122371.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 127747.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 115090.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 107970.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53136.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 114360.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 190892.68, "90th_percentile": 190892.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 190892.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43992.69, "90th_percentile": 51638.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 48355.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42627.19, "90th_percentile": 42627.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42627.19, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 455.0, "90th_percentile": 266205.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 234576.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44669.55, "90th_percentile": 52088.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 50320.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 61550.67, "90th_percentile": 61550.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61550.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90603.9, "90th_percentile": 90603.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90603.9, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12784.29, "90th_percentile": 12784.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12784.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 54877.97, "90th_percentile": 54877.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54877.97, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47241.55, "90th_percentile": 53731.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47545.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 186490.8, "90th_percentile": 186490.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 186490.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 84087.8, "90th_percentile": 84087.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84087.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 44467.83, "90th_percentile": 53737.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49712.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32682.63, "90th_percentile": 32682.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32682.63, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49070.72, "90th_percentile": 49070.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49070.72, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 279486.87, "90th_percentile": 279486.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 279486.87, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 383552.19, "90th_percentile": 383552.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 383552.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4783.47, "90th_percentile": 52520.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 50815.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 185052.67, "90th_percentile": 227868.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 193702.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "316", "type": "MS-DRG" } ], "description": "Other Circulatory System Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15106.62, "minimum": 6507.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15106.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13503.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14096.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12699.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11914.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6507.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12619.23 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6031.5, "90th_percentile": 6059.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6031.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14229.35, "90th_percentile": 14229.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14229.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5773.34, "90th_percentile": 5773.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5773.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6067.24, "90th_percentile": 6067.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6067.24, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3730.76, "90th_percentile": 3730.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3730.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "315", "type": "MS-DRG" } ], "description": "Other Circulatory System Diagnoses With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 21296.66, "minimum": 8691.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21296.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19036.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19872.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17903.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16795.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8691.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17790.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17219.01, "90th_percentile": 17219.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17219.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4709.74, "90th_percentile": 8442.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8140.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17919.75, "90th_percentile": 19845.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18901.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7883.69, "90th_percentile": 8448.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8087.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 36639.95, "90th_percentile": 36639.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36639.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2138.93, "90th_percentile": 2138.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2138.93, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4808.49, "90th_percentile": 4808.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4808.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5996.52, "90th_percentile": 8442.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6883.5, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17155.58, "90th_percentile": 18879.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18879.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11128.03, "90th_percentile": 11128.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11128.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8457.82, "90th_percentile": 8457.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8457.82, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 3757.05, "90th_percentile": 3757.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3757.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5904.34, "90th_percentile": 8212.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8146.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17780.59, "90th_percentile": 17780.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17780.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "314", "type": "MS-DRG" } ], "description": "Other Circulatory System Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 47656.9, "minimum": 17403.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47656.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42598.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44469.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40064.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37585.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17403.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39809.91 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 38868.48, "90th_percentile": 48754.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38868.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1491.74, "90th_percentile": 17190.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 15468.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50350.98, "90th_percentile": 50350.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50350.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 17745.41, "90th_percentile": 17745.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17745.41, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37558.99, "90th_percentile": 37558.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37558.99, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27933.25, "90th_percentile": 59266.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39425.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9050.0, "90th_percentile": 9050.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9050.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15030.14, "90th_percentile": 20264.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16218.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 9166.44, "90th_percentile": 9166.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9166.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5302.92, "90th_percentile": 18638.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7655.32, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11128.03, "90th_percentile": 11128.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11128.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14418.38, "90th_percentile": 17121.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 16386.47, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34747.03, "90th_percentile": 42249.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40909.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15371.22, "90th_percentile": 15371.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15371.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 17114.16, "90th_percentile": 18804.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17238.22, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7050.25, "90th_percentile": 11128.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11128.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17738.04, "90th_percentile": 17745.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17738.04, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42100.93, "90th_percentile": 152462.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42100.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13387.84, "90th_percentile": 20213.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13387.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15523.2, "90th_percentile": 17283.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 16681.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "313", "type": "MS-DRG" } ], "description": "Chest Pain", "standard_charges": [ { "billing_class": "facility", "maximum": 15786.04, "minimum": 6801.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15786.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14110.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14730.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13270.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12449.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6801.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13186.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5751.62, "90th_percentile": 5751.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5751.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14012.6, "90th_percentile": 15013.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14012.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3425.85, "90th_percentile": 3425.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3425.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6108.89, "90th_percentile": 6260.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6108.89, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13272.81, "90th_percentile": 13272.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13272.81, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4384.85, "90th_percentile": 4384.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4384.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 515.08, "90th_percentile": 515.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 515.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "312", "type": "MS-DRG" } ], "description": "Syncope And Collapse", "standard_charges": [ { "billing_class": "facility", "maximum": 19282.74, "minimum": 7979.28, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19282.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17236.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17993.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16210.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15207.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7979.28 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16107.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20371.87, "90th_percentile": 20371.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20371.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6319.82, "90th_percentile": 7451.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 6832.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15989.87, "90th_percentile": 18168.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17114.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7084.51, "90th_percentile": 7084.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7084.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5324.94, "90th_percentile": 7469.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 7143.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 7890.34, "90th_percentile": 7890.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7890.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4927.46, "90th_percentile": 4927.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4927.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6197.66, "90th_percentile": 7822.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7176.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26280.33, "90th_percentile": 26280.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26280.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 6755.73, "90th_percentile": 7480.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7451.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8238.75, "90th_percentile": 8238.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8238.75, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5443.67, "90th_percentile": 5443.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5443.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6082.51, "90th_percentile": 6082.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6082.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15207.67, "90th_percentile": 15207.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15207.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5910.9, "90th_percentile": 7558.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6784.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2466.0, "90th_percentile": 16082.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14807.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "311", "type": "MS-DRG" } ], "description": "Angina Pectoris", "standard_charges": [ { "billing_class": "facility", "maximum": 15458.5, "minimum": 6661.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15458.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13817.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14424.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12995.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12191.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6661.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12913.17 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "310", "type": "MS-DRG" } ], "description": "Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 12382.29, "minimum": 5606.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12382.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11068.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 11554.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10409.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9765.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10343.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8923.03, "90th_percentile": 20854.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8923.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4331.33, "90th_percentile": 5123.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5104.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13081.67, "90th_percentile": 13081.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13081.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 396.59, "90th_percentile": 11319.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10989.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4201.44, "90th_percentile": 5515.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4703.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4484.68, "90th_percentile": 4484.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4484.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 30678.68, "90th_percentile": 30678.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30678.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4683.26, "90th_percentile": 9112.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5109.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 5119.56, "90th_percentile": 5119.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5119.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 5999.95, "90th_percentile": 5999.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5999.95, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10327.25, "90th_percentile": 10327.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10327.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4765.42, "90th_percentile": 4765.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4765.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9765.51, "90th_percentile": 9888.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9765.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "309", "type": "MS-DRG" } ], "description": "Cardiac Arrhythmia And Conduction Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 16361.45, "minimum": 6923.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16361.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14624.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15267.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13754.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12903.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6923.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13667.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17285.57, "90th_percentile": 17285.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17285.57, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4813.74, "90th_percentile": 6730.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 5959.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12790.78, "90th_percentile": 15415.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 14521.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5371.07, "90th_percentile": 5371.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5371.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 666.31, "90th_percentile": 6467.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5845.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 7132.34, "90th_percentile": 7132.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7132.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4783.65, "90th_percentile": 4783.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4783.65, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3401.34, "90th_percentile": 4566.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4484.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4872.97, "90th_percentile": 4872.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4872.97, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 16068.69, "90th_percentile": 16068.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16068.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5206.54, "90th_percentile": 6482.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 5973.73, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6075.29, "90th_percentile": 14504.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10801.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 5822.05, "90th_percentile": 6478.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5822.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6724.28, "90th_percentile": 6724.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6724.28, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23414.4, "90th_percentile": 23414.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23414.4, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13579.55, "90th_percentile": 13579.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13579.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2435.25, "90th_percentile": 2435.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2435.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4795.16, "90th_percentile": 6560.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 6321.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9625.15, "90th_percentile": 13646.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12903.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "308", "type": "MS-DRG" } ], "description": "Cardiac Arrhythmia And Conduction Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 26689.99, "minimum": 10560.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26689.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23857.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24905.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22437.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21049.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22295.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 24593.65, "90th_percentile": 24593.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24593.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 861.33, "90th_percentile": 10008.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 9433.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 9332.72, "90th_percentile": 9332.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9332.72, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25105.81, "90th_percentile": 25105.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25105.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6997.5, "90th_percentile": 6997.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6997.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8328.55, "90th_percentile": 10021.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 9114.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6973.0, "90th_percentile": 6973.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6973.0, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6537.18, "90th_percentile": 6537.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6537.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10066.22, "90th_percentile": 10066.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10066.22, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 24354.82, "90th_percentile": 24354.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24354.82, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10450.34, "90th_percentile": 10450.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10450.34, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7888.27, "90th_percentile": 10258.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 9970.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23313.07, "90th_percentile": 23313.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23313.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 9349.26, "90th_percentile": 9349.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9349.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10055.31, "90th_percentile": 10055.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10055.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 9416.36, "90th_percentile": 9416.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9416.36, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7838.15, "90th_percentile": 7838.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7838.15, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22223.43, "90th_percentile": 22223.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22223.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4698.23, "90th_percentile": 4698.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4698.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8311.96, "90th_percentile": 10470.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9041.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21047.78, "90th_percentile": 22258.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21047.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "307", "type": "MS-DRG" } ], "description": "Cardiac Congenital And Valvular Disorders Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20499.95, "minimum": 8302.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20499.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18324.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19129.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17233.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16167.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8302.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17124.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7888.34, "90th_percentile": 7888.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7888.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7216.63, "90th_percentile": 7216.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7216.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7867.09, "90th_percentile": 8139.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7867.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "306", "type": "MS-DRG" } ], "description": "Cardiac Congenital And Valvular Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33138.96, "minimum": 13447.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33138.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29621.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30922.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27859.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26135.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13447.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27682.43 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10818.12, "90th_percentile": 12207.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11121.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12165.89, "90th_percentile": 12207.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12173.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8695.85, "90th_percentile": 8695.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8695.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12165.83, "90th_percentile": 12207.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12165.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10443.55, "90th_percentile": 10443.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10443.55, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 12090.8, "90th_percentile": 12090.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12090.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12311.93, "90th_percentile": 12311.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12311.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "305", "type": "MS-DRG" } ], "description": "Hypertension Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16613.74, "minimum": 7074.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16613.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14850.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15502.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13966.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13102.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7074.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13878.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 12676.5, "90th_percentile": 12676.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12676.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6633.68, "90th_percentile": 6633.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6633.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11947.61, "90th_percentile": 15556.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14275.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4947.59, "90th_percentile": 4947.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4947.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6386.4, "90th_percentile": 6386.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6386.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3983.58, "90th_percentile": 3983.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3983.58, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4762.22, "90th_percentile": 4762.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4762.22, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5170.46, "90th_percentile": 5170.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5170.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6122.9, "90th_percentile": 6560.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6181.23, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14727.98, "90th_percentile": 14727.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14727.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5170.46, "90th_percentile": 5170.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5170.46, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13856.42, "90th_percentile": 13856.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13856.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4687.33, "90th_percentile": 7172.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4687.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "304", "type": "MS-DRG" } ], "description": "Hypertension With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25999.5, "minimum": 10451.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25999.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23239.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24260.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21857.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20504.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10451.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21718.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22483.66, "90th_percentile": 22483.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22483.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9734.7, "90th_percentile": 9734.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9734.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22698.3, "90th_percentile": 22698.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22698.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6739.31, "90th_percentile": 6739.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6739.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9736.45, "90th_percentile": 9736.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9736.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4923.75, "90th_percentile": 6457.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6375.02, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7042.88, "90th_percentile": 7042.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7042.88, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9767.43, "90th_percentile": 9767.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9767.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9669.09, "90th_percentile": 9669.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9669.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 9751.66, "90th_percentile": 9751.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9751.66, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8147.8, "90th_percentile": 8147.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8147.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20504.96, "90th_percentile": 20504.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20504.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "303", "type": "MS-DRG" } ], "description": "Atherosclerosis Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14880.88, "minimum": 6438.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14880.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13301.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13885.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12510.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11736.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6438.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12430.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15740.09, "90th_percentile": 15740.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15740.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5982.65, "90th_percentile": 5982.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5982.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4736.51, "90th_percentile": 4736.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4736.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13191.82, "90th_percentile": 13191.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13191.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 5323.16, "90th_percentile": 5323.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5323.16, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "302", "type": "MS-DRG" } ], "description": "Atherosclerosis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25742.78, "minimum": 10503.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25742.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23010.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24021.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20302.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10503.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21504.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 20349.62, "90th_percentile": 20349.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20349.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9597.47, "90th_percentile": 9680.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9653.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1085.74, "90th_percentile": 1085.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1085.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "301", "type": "MS-DRG" } ], "description": "Peripheral Vascular Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15786.04, "minimum": 6799.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15786.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14110.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14730.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13270.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12449.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6799.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13186.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16827.31, "90th_percentile": 16827.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16827.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18877.66, "90th_percentile": 18877.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18877.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3539.68, "90th_percentile": 3539.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3539.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5023.59, "90th_percentile": 5023.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5023.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 18675.71, "90th_percentile": 18675.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18675.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4704.04, "90th_percentile": 4704.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4704.04, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5199.2, "90th_percentile": 5199.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5199.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6318.27, "90th_percentile": 6318.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6318.27, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13065.9, "90th_percentile": 13065.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13065.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4680.19, "90th_percentile": 6666.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5590.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12532.32, "90th_percentile": 12532.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12532.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6830.64, "90th_percentile": 6830.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6830.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6323.9, "90th_percentile": 6323.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6323.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11514.26, "90th_percentile": 11514.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11514.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "300", "type": "MS-DRG" } ], "description": "Peripheral Vascular Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23691.24, "minimum": 9500.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23691.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21176.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22106.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19916.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18684.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9500.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19790.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16189.35, "90th_percentile": 23693.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16189.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6548.03, "90th_percentile": 8980.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 8190.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5729.03, "90th_percentile": 5729.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5729.03, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12006.51, "90th_percentile": 22259.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14065.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5395.33, "90th_percentile": 5395.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5395.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6827.98, "90th_percentile": 9319.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7969.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 7047.33, "90th_percentile": 7047.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7047.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4665.98, "90th_percentile": 5899.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4665.98, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3430.16, "90th_percentile": 5103.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4459.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5638.37, "90th_percentile": 5638.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5638.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7172.88, "90th_percentile": 8958.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8713.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21004.1, "90th_percentile": 21004.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21004.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8994.26, "90th_percentile": 8994.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8994.26, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4923.28, "90th_percentile": 5638.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4923.28, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9040.31, "90th_percentile": 9040.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9040.31, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16241.34, "90th_percentile": 16241.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16241.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6084.93, "90th_percentile": 6084.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6084.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6493.82, "90th_percentile": 9036.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7900.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18686.25, "90th_percentile": 19756.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19703.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "299", "type": "MS-DRG" } ], "description": "Peripheral Vascular Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35801.32, "minimum": 13889.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35801.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32001.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33407.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30097.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28235.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13889.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29906.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 32640.73, "90th_percentile": 33688.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32640.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8996.88, "90th_percentile": 13129.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 11937.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5638.37, "90th_percentile": 5638.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5638.37, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28822.9, "90th_percentile": 31772.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28822.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10901.37, "90th_percentile": 10901.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10901.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10983.62, "90th_percentile": 13617.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 13074.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 11656.04, "90th_percentile": 11656.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11656.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6954.83, "90th_percentile": 6954.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6954.83, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5103.69, "90th_percentile": 13089.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6227.42, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 183.55, "90th_percentile": 183.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 183.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 17374.94, "90th_percentile": 17374.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17374.94, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7338.15, "90th_percentile": 13118.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11727.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30095.45, "90th_percentile": 31735.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30095.45, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10035.58, "90th_percentile": 10035.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10035.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3908.4, "90th_percentile": 3908.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3908.4, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11914.68, "90th_percentile": 11914.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11914.68, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27136.7, "90th_percentile": 30136.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27136.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6830.64, "90th_percentile": 6830.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6830.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11288.17, "90th_percentile": 13294.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12023.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28233.59, "90th_percentile": 28233.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28233.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "298", "type": "MS-DRG" } ], "description": "Cardiac Arrest, Unexplained Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 9773.05, "minimum": 4744.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9773.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 8735.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 9119.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 8215.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 7707.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4744.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 8163.86 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "297", "type": "MS-DRG" } ], "description": "Cardiac Arrest, Unexplained With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 15589.08, "minimum": 6134.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15589.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13934.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14546.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13105.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12294.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6134.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13022.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "296", "type": "MS-DRG" } ], "description": "Cardiac Arrest, Unexplained With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36257.22, "minimum": 13340.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36257.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32408.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33832.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30480.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28594.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13340.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30287.25 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13244.6, "90th_percentile": 13244.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13244.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13236.72, "90th_percentile": 13236.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13236.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14100.05, "90th_percentile": 14100.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14100.05, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13274.01, "90th_percentile": 13274.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13274.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11349.2, "90th_percentile": 11349.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11349.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9771.91, "90th_percentile": 9771.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9771.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 14771.48, "90th_percentile": 14771.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14771.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11440.83, "90th_percentile": 13446.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12256.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "295", "type": "MS-DRG" } ], "description": "Deep Vein Thrombophlebitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17479.06, "minimum": 13785.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17479.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15623.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16310.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14694.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13785.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14601.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "294", "type": "MS-DRG" } ], "description": "Deep Vein Thrombophlebitis With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27174.65, "minimum": 21431.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27174.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24290.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25357.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22845.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21431.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22700.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "293", "type": "MS-DRG" } ], "description": "Heart Failure And Shock Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 12149.92, "minimum": 5606.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12149.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10860.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 11337.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10214.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9582.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5606.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10149.36 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4293.2, "90th_percentile": 4293.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4293.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "292", "type": "MS-DRG" } ], "description": "Heart Failure And Shock With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 19061.43, "minimum": 7803.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19061.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17038.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17786.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16024.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15033.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7803.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15922.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6768.83, "90th_percentile": 7376.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6768.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16915.69, "90th_percentile": 16915.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16915.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5698.13, "90th_percentile": 5698.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5698.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6795.51, "90th_percentile": 6795.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6795.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 13235.69, "90th_percentile": 13235.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13235.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5308.05, "90th_percentile": 5308.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5308.05, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5688.71, "90th_percentile": 5688.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5688.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8070.31, "90th_percentile": 8070.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8070.31, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5532.02, "90th_percentile": 5532.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5532.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "291", "type": "MS-DRG" } ], "description": "Heart Failure And Shock With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28878.74, "minimum": 11180.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28878.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25813.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26947.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24277.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22775.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11180.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24123.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 21397.25, "90th_percentile": 28599.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21546.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7723.42, "90th_percentile": 10759.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "163", "median_amount": 9796.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30507.53, "90th_percentile": 30507.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30507.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 1128.38, "90th_percentile": 10760.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10182.85, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5864.14, "90th_percentile": 8160.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8070.31, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18311.8, "90th_percentile": 26769.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 24753.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5611.37, "90th_percentile": 7809.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7350.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8393.86, "90th_percentile": 10816.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "102", "median_amount": 10657.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12876.83, "90th_percentile": 12876.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12876.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8436.41, "90th_percentile": 42407.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10123.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4802.53, "90th_percentile": 7792.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 6609.3, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5308.05, "90th_percentile": 7387.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 5390.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11059.25, "90th_percentile": 11061.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11061.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 95218.42, "90th_percentile": 95218.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 95218.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 24362.67, "90th_percentile": 28359.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27453.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 28359.83, "90th_percentile": 28359.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28359.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8795.92, "90th_percentile": 10920.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9020.92, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8160.97, "90th_percentile": 8160.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8160.97, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8466.82, "90th_percentile": 10766.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "145", "median_amount": 9789.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19894.99, "90th_percentile": 25598.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 22679.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 10129.19, "90th_percentile": 15286.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10129.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7806.86, "90th_percentile": 10860.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 9791.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 1219.11, "90th_percentile": 10764.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 10197.56, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3964.43, "90th_percentile": 13783.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8070.31, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8755.65, "90th_percentile": 11142.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 11108.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22773.98, "90th_percentile": 24084.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23696.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5560.82, "90th_percentile": 7652.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6195.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7826.8, "90th_percentile": 10895.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "93", "median_amount": 9936.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22773.98, "90th_percentile": 23696.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 22804.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "290", "type": "MS-DRG" } ], "description": "Acute And Subacute Endocarditis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21666.25, "minimum": 8430.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21666.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19366.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20217.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18214.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17087.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8430.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18098.77 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "289", "type": "MS-DRG" } ], "description": "Acute And Subacute Endocarditis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 34891.73, "minimum": 14466.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34891.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31188.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32558.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29332.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27517.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14466.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29146.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7026.53, "90th_percentile": 7026.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7026.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "288", "type": "MS-DRG" } ], "description": "Acute And Subacute Endocarditis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 60446.4, "minimum": 22226.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60446.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 54030.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 56404.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50815.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47672.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22226.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50493.54 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21558.23, "90th_percentile": 21558.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21558.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 20551.04, "90th_percentile": 20551.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20551.04, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13191.81, "90th_percentile": 13565.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13255.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 21879.52, "90th_percentile": 21879.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21879.52, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18697.57, "90th_percentile": 18697.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18697.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 23907.27, "90th_percentile": 23907.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23907.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9440.47, "90th_percentile": 9440.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9440.47, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13887.18, "90th_percentile": 13887.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13887.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21662.32, "90th_percentile": 21662.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21662.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "287", "type": "MS-DRG" } ], "description": "Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24113.94, "minimum": 9520.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24113.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21554.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22501.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20272.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19017.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9520.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20143.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 24093.27, "90th_percentile": 24093.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24093.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7568.0, "90th_percentile": 9255.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8339.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25478.28, "90th_percentile": 25478.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25478.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8429.42, "90th_percentile": 8429.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8429.42, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17568.36, "90th_percentile": 22313.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21361.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6347.16, "90th_percentile": 6347.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6347.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7919.93, "90th_percentile": 9248.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8334.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 16441.26, "90th_percentile": 16441.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16441.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7695.16, "90th_percentile": 7695.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7695.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6198.93, "90th_percentile": 7712.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6198.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 23684.63, "90th_percentile": 23684.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23684.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8187.44, "90th_percentile": 9343.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 9113.24, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20325.16, "90th_percentile": 21378.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21378.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 5893.74, "90th_percentile": 5893.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5893.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6124.0, "90th_percentile": 6124.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6124.0, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7856.97, "90th_percentile": 7856.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7856.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 9980.7, "90th_percentile": 9980.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9980.7, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7993.41, "90th_percentile": 7993.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7993.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7863.12, "90th_percentile": 9176.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8485.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19019.62, "90th_percentile": 19751.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19019.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "286", "type": "MS-DRG" } ], "description": "Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 48982.54, "minimum": 18394.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48982.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 43783.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 45706.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41178.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38630.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18394.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40917.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 39942.35, "90th_percentile": 48936.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48936.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15335.38, "90th_percentile": 17576.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 16015.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 325151.57, "90th_percentile": 325151.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 325151.57, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 16832.66, "90th_percentile": 16832.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16832.66, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10699.62, "90th_percentile": 19868.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12872.86, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39051.25, "90th_percentile": 307664.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43783.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 12317.99, "90th_percentile": 19011.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12317.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15980.34, "90th_percentile": 17720.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 16790.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 36094.19, "90th_percentile": 36094.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36094.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10542.43, "90th_percentile": 20753.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12428.96, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46631.23, "90th_percentile": 46631.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46631.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6004.07, "90th_percentile": 19538.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11652.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32816.42, "90th_percentile": 32816.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32816.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 48106.08, "90th_percentile": 48106.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48106.08, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 16391.33, "90th_percentile": 16391.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16391.33, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 12872.86, "90th_percentile": 12872.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12872.86, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15122.41, "90th_percentile": 17869.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 16748.53, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43422.73, "90th_percentile": 187169.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 179652.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15572.07, "90th_percentile": 17608.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15572.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12872.86, "90th_percentile": 12963.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12872.86, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35.0, "90th_percentile": 35.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 12207.02, "90th_percentile": 12207.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12207.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15021.44, "90th_percentile": 18042.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 16249.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38221.93, "90th_percentile": 40853.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38630.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "285", "type": "MS-DRG" } ], "description": "Acute Myocardial Infarction, Expired Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 12422.13, "minimum": 5861.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12422.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11103.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 11591.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10442.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9796.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5861.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10376.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "284", "type": "MS-DRG" } ], "description": "Acute Myocardial Infarction, Expired With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 16396.86, "minimum": 6586.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16396.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14656.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15300.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13784.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12931.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6586.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13697.02 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5702.47, "90th_percentile": 5702.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5702.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "283", "type": "MS-DRG" } ], "description": "Acute Myocardial Infarction, Expired With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43274.96, "minimum": 16593.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43274.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38681.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40380.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36380.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34129.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16593.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36149.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15734.27, "90th_percentile": 15734.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15734.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14706.23, "90th_percentile": 16119.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15671.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 37494.05, "90th_percentile": 37494.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37494.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13486.11, "90th_percentile": 15851.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14394.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34915.48, "90th_percentile": 34915.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34915.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 15744.15, "90th_percentile": 15744.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15744.15, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7712.02, "90th_percentile": 7712.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7712.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 14771.48, "90th_percentile": 14771.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14771.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15769.85, "90th_percentile": 16266.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15811.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31619.69, "90th_percentile": 31619.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31619.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "282", "type": "MS-DRG" } ], "description": "Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16047.19, "minimum": 6826.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16047.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14343.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14974.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13490.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12655.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6826.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13404.92 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5831.52, "90th_percentile": 5831.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5831.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4954.5, "90th_percentile": 4954.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4954.5, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14348.16, "90th_percentile": 14348.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14348.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6667.72, "90th_percentile": 6667.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6667.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14186.5, "90th_percentile": 14186.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14186.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 6392.01, "90th_percentile": 6392.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6392.01, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10614.78, "90th_percentile": 10614.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10614.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10757.53, "90th_percentile": 12655.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12655.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "281", "type": "MS-DRG" } ], "description": "Acute Myocardial Infarction, Discharged Alive With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 20400.36, "minimum": 8348.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20400.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18235.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19036.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17150.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16089.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8348.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17041.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 21552.61, "90th_percentile": 21552.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21552.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5536.69, "90th_percentile": 7838.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 7185.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13433.77, "90th_percentile": 19221.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 18106.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5846.19, "90th_percentile": 5846.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5846.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6185.32, "90th_percentile": 8227.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7174.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 5321.59, "90th_percentile": 5321.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5321.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2501.17, "90th_percentile": 2501.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2501.17, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5530.18, "90th_percentile": 5530.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5530.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 39207.68, "90th_percentile": 39207.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39207.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 18984.15, "90th_percentile": 18984.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18984.15, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 5829.08, "90th_percentile": 5829.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5829.08, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5573.76, "90th_percentile": 7841.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6866.87, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16156.94, "90th_percentile": 16156.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16156.94, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7195.41, "90th_percentile": 7195.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7195.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7831.1, "90th_percentile": 7831.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7831.1, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5793.52, "90th_percentile": 5793.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5793.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5993.18, "90th_percentile": 7766.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6574.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15290.49, "90th_percentile": 16964.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15290.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "280", "type": "MS-DRG" } ], "description": "Acute Myocardial Infarction, Discharged Alive With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36328.04, "minimum": 13667.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36328.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32472.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33898.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30540.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28650.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13667.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30346.41 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30189.0, "90th_percentile": 37505.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36325.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10488.44, "90th_percentile": 13292.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 12095.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7712.02, "90th_percentile": 21315.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11916.6, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31427.75, "90th_percentile": 32470.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 32240.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5611.37, "90th_percentile": 5611.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5611.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9326.4, "90th_percentile": 13296.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11824.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3994.21, "90th_percentile": 11131.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5898.86, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6537.18, "90th_percentile": 6980.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6537.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 11406.39, "90th_percentile": 11406.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11406.39, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11118.05, "90th_percentile": 13301.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 12847.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32080.62, "90th_percentile": 32080.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32080.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 1147.56, "90th_percentile": 1147.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1147.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7712.02, "90th_percentile": 7712.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7712.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13866.57, "90th_percentile": 15828.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13866.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29220.16, "90th_percentile": 29220.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29220.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5879.5, "90th_percentile": 11300.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5879.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11626.12, "90th_percentile": 13522.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12566.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30296.96, "90th_percentile": 30296.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30296.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "279", "type": "MS-DRG" } ], "description": "Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 70912.15, "minimum": 29217.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70912.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63385.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 66169.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59614.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55926.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29217.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 59236.05 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28373.98, "90th_percentile": 28373.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28373.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 62940.82, "90th_percentile": 62940.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62940.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9655.42, "90th_percentile": 9655.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9655.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25059.33, "90th_percentile": 25059.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25059.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 15854.34, "90th_percentile": 15854.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15854.34, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 25071.92, "90th_percentile": 25071.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25071.92, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22861.85, "90th_percentile": 25138.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24577.05, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23230.25, "90th_percentile": 28642.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23804.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "278", "type": "MS-DRG" } ], "description": "Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 110719.18, "minimum": 44436.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110719.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 98967.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 103314.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93078.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87320.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44436.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92488.61 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42147.7, "90th_percentile": 42147.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42147.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41970.19, "90th_percentile": 43962.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41970.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "277", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 102957.84, "minimum": 37077.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102957.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 92029.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 96072.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86554.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81199.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37077.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86005.22 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34265.68, "90th_percentile": 34265.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34265.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90433.29, "90th_percentile": 239736.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 96304.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35414.21, "90th_percentile": 36027.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35704.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33209.06, "90th_percentile": 33209.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33209.06, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8442.64, "90th_percentile": 8442.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8442.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 253570.19, "90th_percentile": 253570.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 253570.19, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 109295.13, "90th_percentile": 109295.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 109295.13, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31878.25, "90th_percentile": 36359.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34101.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 122802.58, "90th_percentile": 122802.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 122802.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 76905.97, "90th_percentile": 76905.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76905.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33182.43, "90th_percentile": 33182.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33182.43, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 236087.06, "90th_percentile": 236087.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 236087.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33001.0, "90th_percentile": 34414.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33001.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 110711.9, "90th_percentile": 111220.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110711.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "276", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator", "standard_charges": [ { "billing_class": "facility", "maximum": 137079.41, "minimum": 47856.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 137079.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 122529.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 127912.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 115239.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 108110.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47856.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 114508.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 273338.32, "90th_percentile": 273338.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 273338.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42659.24, "90th_percentile": 46861.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43661.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 121670.4, "90th_percentile": 278443.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121670.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47779.09, "90th_percentile": 47779.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47779.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 56460.87, "90th_percentile": 56460.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56460.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 31057.36, "90th_percentile": 31057.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31057.36, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 28872.43, "90th_percentile": 34392.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30117.89, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44411.04, "90th_percentile": 47596.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47163.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 47596.44, "90th_percentile": 47596.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47596.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43616.24, "90th_percentile": 48051.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46915.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "275", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 156388.71, "minimum": 56583.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 156388.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 139789.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 145930.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131472.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 123338.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56583.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 130638.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 52633.45, "90th_percentile": 54576.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52633.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 308661.2, "90th_percentile": 308661.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 308661.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 34310.39, "90th_percentile": 34310.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34310.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 51923.22, "90th_percentile": 54195.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53222.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 183171.58, "90th_percentile": 183171.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 183171.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 53495.47, "90th_percentile": 53495.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53495.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 267881.04, "90th_percentile": 267881.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 267881.04, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 48542.36, "90th_percentile": 48542.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48542.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 53359.57, "90th_percentile": 53359.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53359.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 185764.94, "90th_percentile": 185764.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 185764.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "274", "type": "MS-DRG" } ], "description": "Percutaneous And Other Intracardiac Procedures Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 69066.42, "minimum": 26773.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69066.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 61735.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 64447.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58062.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54470.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26773.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57694.23 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 69070.85, "90th_percentile": 72548.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69070.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22194.93, "90th_percentile": 24593.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 24241.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 72972.1, "90th_percentile": 72972.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72972.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61302.68, "90th_percentile": 61739.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61739.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 17576.52, "90th_percentile": 17576.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17576.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21916.58, "90th_percentile": 25706.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 24139.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 50962.4, "90th_percentile": 50962.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50962.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 11566.73, "90th_percentile": 11566.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11566.73, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12784.29, "90th_percentile": 12784.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12784.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20145.71, "90th_percentile": 20145.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20145.71, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 24555.3, "90th_percentile": 24942.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24855.3, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22276.64, "90th_percentile": 26454.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 24409.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 61230.9, "90th_percentile": 61230.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61230.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 22287.81, "90th_percentile": 26015.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24213.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 24816.52, "90th_percentile": 24816.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24816.52, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6633.07, "90th_percentile": 6633.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6633.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25562.2, "90th_percentile": 25562.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25562.2, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11240.49, "90th_percentile": 20495.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13393.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24233.31, "90th_percentile": 24829.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 24640.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 54289.32, "90th_percentile": 142751.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54473.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "273", "type": "MS-DRG" } ], "description": "Percutaneous And Other Intracardiac Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 86532.21, "minimum": 33248.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86532.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 80745.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72745.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68245.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33248.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72284.17 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29349.55, "90th_percentile": 77381.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29733.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 35673.47, "90th_percentile": 35673.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35673.47, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 73652.29, "90th_percentile": 84993.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75599.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27707.07, "90th_percentile": 36565.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28897.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 28894.79, "90th_percentile": 28894.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28894.79, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12784.29, "90th_percentile": 12784.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12784.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 130263.18, "90th_percentile": 130263.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 130263.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 174033.64, "90th_percentile": 174033.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 174033.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 91062.86, "90th_percentile": 91062.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 91062.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30364.15, "90th_percentile": 38484.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30456.06, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43388.6, "90th_percentile": 43388.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43388.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 30052.05, "90th_percentile": 30052.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30052.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 37030.36, "90th_percentile": 37030.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37030.36, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18368.25, "90th_percentile": 20801.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18368.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29832.06, "90th_percentile": 29832.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29832.06, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2951.35, "90th_percentile": 39151.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29556.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 188680.7, "90th_percentile": 188680.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 188680.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "272", "type": "MS-DRG" } ], "description": "Other Major Cardiovascular Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 55371.76, "minimum": 21036.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55371.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49494.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 51668.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46549.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43669.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21036.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46254.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 383045.14, "90th_percentile": 383045.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 383045.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18464.78, "90th_percentile": 18464.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18464.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49498.52, "90th_percentile": 53235.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49498.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19744.83, "90th_percentile": 19744.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19744.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16624.95, "90th_percentile": 16624.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16624.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 18366.62, "90th_percentile": 18366.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18366.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18653.89, "90th_percentile": 18653.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18653.89, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 47655.66, "90th_percentile": 47655.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47655.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20705.46, "90th_percentile": 20705.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20705.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 54189.61, "90th_percentile": 54189.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54189.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "271", "type": "MS-DRG" } ], "description": "Other Major Cardiovascular Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 76228.02, "minimum": 28828.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76228.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 68137.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 71130.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64083.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60118.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28828.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63676.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 75021.25, "90th_percentile": 75021.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75021.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24418.18, "90th_percentile": 26860.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 25462.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 27129.54, "90th_percentile": 27129.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27129.54, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17671.17, "90th_percentile": 17671.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17671.17, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 67654.9, "90th_percentile": 336649.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68137.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 23856.53, "90th_percentile": 23856.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23856.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25214.41, "90th_percentile": 26935.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25945.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 59278.33, "90th_percentile": 59278.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59278.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 16974.28, "90th_percentile": 16974.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16974.28, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 14863.44, "90th_percentile": 14863.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14863.44, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 91758.18, "90th_percentile": 91758.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 91758.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 78629.39, "90th_percentile": 78629.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78629.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 28526.0, "90th_percentile": 28526.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28526.0, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24703.61, "90th_percentile": 26866.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 25357.73, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 2441.49, "90th_percentile": 2441.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2441.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16420.57, "90th_percentile": 16420.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16420.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27382.37, "90th_percentile": 27382.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27382.37, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 198681.0, "90th_percentile": 198681.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 198681.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5179.35, "90th_percentile": 5179.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5179.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24558.19, "90th_percentile": 27288.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25366.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 61729.79, "90th_percentile": 61729.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61729.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "270", "type": "MS-DRG" } ], "description": "Other Major Cardiovascular Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 113594.0, "minimum": 42185.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113594.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 101537.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 105997.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95495.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 89587.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42185.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 94890.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 118058.67, "90th_percentile": 160703.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 118058.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35938.61, "90th_percentile": 41003.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 38937.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 51936.25, "90th_percentile": 331614.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 100822.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9171.04, "90th_percentile": 9199.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9171.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37638.5, "90th_percentile": 40728.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 39573.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 54830.03, "90th_percentile": 73865.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54830.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5688.79, "90th_percentile": 5688.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5688.79, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10786.58, "90th_percentile": 79838.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36874.54, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38290.82, "90th_percentile": 38290.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38290.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 38641.97, "90th_percentile": 41742.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38641.97, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38193.13, "90th_percentile": 68139.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 39591.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 103455.33, "90th_percentile": 103455.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 103455.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 34021.58, "90th_percentile": 34021.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34021.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 39587.11, "90th_percentile": 39591.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39587.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40737.59, "90th_percentile": 40737.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40737.59, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42471.89, "90th_percentile": 42471.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42471.89, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 231062.13, "90th_percentile": 231062.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 231062.13, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 89591.38, "90th_percentile": 100341.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 89591.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 21337.86, "90th_percentile": 21337.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21337.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34540.82, "90th_percentile": 40069.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 38907.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 94744.91, "90th_percentile": 94744.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 94744.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "269", "type": "MS-DRG" } ], "description": "Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 92073.81, "minimum": 34007.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92073.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 82301.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 85916.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77404.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72615.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34007.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76913.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29312.92, "90th_percentile": 32357.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 32259.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 332851.55, "90th_percentile": 332851.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 332851.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 16909.48, "90th_percentile": 16909.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16909.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32951.48, "90th_percentile": 32951.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32951.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 117180.92, "90th_percentile": 117180.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 117180.92, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 32835.97, "90th_percentile": 32835.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32835.97, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30117.67, "90th_percentile": 32267.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31827.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 42364.28, "90th_percentile": 42364.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42364.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 31979.48, "90th_percentile": 31979.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31979.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14377.59, "90th_percentile": 14377.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14377.59, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 17416.62, "90th_percentile": 17416.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17416.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32007.97, "90th_percentile": 34337.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32552.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 160062.93, "90th_percentile": 160062.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 160062.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "268", "type": "MS-DRG" } ], "description": "Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 147551.8, "minimum": 54623.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147551.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 131890.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 137684.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 124043.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 116369.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54623.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 123256.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 197070.4, "90th_percentile": 197070.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 197070.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50914.51, "90th_percentile": 50914.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50914.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 130637.55, "90th_percentile": 130965.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 130637.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 17574.95, "90th_percentile": 17574.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17574.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48607.71, "90th_percentile": 48607.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48607.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 73169.87, "90th_percentile": 73169.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73169.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 31106.81, "90th_percentile": 31106.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31106.81, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50714.31, "90th_percentile": 50714.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50714.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 179228.56, "90th_percentile": 179228.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 179228.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 51771.96, "90th_percentile": 51771.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51771.96, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 37943.97, "90th_percentile": 37943.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37943.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49852.44, "90th_percentile": 51629.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50323.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 208346.35, "90th_percentile": 208346.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 208346.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "267", "type": "MS-DRG" } ], "description": "Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 104113.08, "minimum": 38182.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104113.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 93062.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 97150.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87525.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82110.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38182.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86970.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33008.32, "90th_percentile": 37101.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "73", "median_amount": 35984.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 127567.75, "90th_percentile": 127567.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 127567.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 92409.72, "90th_percentile": 214271.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 93068.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33384.51, "90th_percentile": 37102.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 36361.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 41631.12, "90th_percentile": 41631.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41631.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 37431.67, "90th_percentile": 37431.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37431.67, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33688.31, "90th_percentile": 37434.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "57", "median_amount": 36361.61, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 152961.51, "90th_percentile": 152961.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 152961.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 36013.72, "90th_percentile": 37094.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 36361.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 154752.97, "90th_percentile": 154752.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 154752.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 44853.91, "90th_percentile": 44853.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44853.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34764.38, "90th_percentile": 37480.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 36682.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 142011.39, "90th_percentile": 155908.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 148517.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "266", "type": "MS-DRG" } ], "description": "Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 132573.54, "minimum": 48802.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 132573.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 118502.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 123707.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111451.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 104556.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48802.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 110744.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37278.39, "90th_percentile": 46395.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 42651.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 47663.65, "90th_percentile": 47663.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47663.65, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 127789.4, "90th_percentile": 263076.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 127789.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41506.39, "90th_percentile": 46883.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 46060.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 65080.97, "90th_percentile": 65080.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65080.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 38737.47, "90th_percentile": 38737.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38737.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 42897.16, "90th_percentile": 42897.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42897.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 42736.3, "90th_percentile": 42736.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42736.3, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41838.46, "90th_percentile": 52997.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 45991.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 252324.01, "90th_percentile": 252324.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 252324.01, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 44225.52, "90th_percentile": 76422.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45742.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 47234.3, "90th_percentile": 47234.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47234.3, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49133.65, "90th_percentile": 49133.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49133.65, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39748.01, "90th_percentile": 48281.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 46458.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 181107.58, "90th_percentile": 181107.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 181107.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "265", "type": "MS-DRG" } ], "description": "Aicd Lead Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 78939.06, "minimum": 29308.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78939.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70560.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 73660.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66362.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62256.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29308.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 65941.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 24860.03, "90th_percentile": 24860.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24860.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 12107.52, "90th_percentile": 12107.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12107.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 232834.98, "90th_percentile": 232834.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 232834.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27864.53, "90th_percentile": 27864.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27864.53, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 124356.48, "90th_percentile": 124356.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 124356.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "264", "type": "MS-DRG" } ], "description": "Other Circulatory System O.R. Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 77345.63, "minimum": 27153.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77345.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69136.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 72173.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65022.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60999.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27153.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64610.22 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18197.09, "90th_percentile": 27247.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26115.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 68650.75, "90th_percentile": 68650.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68650.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24127.3, "90th_percentile": 27267.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26288.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6954.83, "90th_percentile": 6954.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6954.83, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7630.08, "90th_percentile": 16576.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7630.08, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 162849.44, "90th_percentile": 162849.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 162849.44, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26071.1, "90th_percentile": 43173.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26071.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2389.84, "90th_percentile": 2389.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2389.84, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7993.41, "90th_percentile": 7993.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7993.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25855.7, "90th_percentile": 27239.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25855.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 63055.58, "90th_percentile": 63055.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63055.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "263", "type": "MS-DRG" } ], "description": "Vein Ligation And Stripping", "standard_charges": [ { "billing_class": "facility", "maximum": 59353.13, "minimum": 24953.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59353.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53053.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 55383.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49896.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46809.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24953.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49580.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22723.21, "90th_percentile": 22723.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22723.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30999.46, "90th_percentile": 30999.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30999.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "262", "type": "MS-DRG" } ], "description": "Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33588.22, "minimum": 13868.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33588.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30023.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31342.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28236.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26489.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13868.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28057.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30025.12, "90th_percentile": 30025.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30025.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "261", "type": "MS-DRG" } ], "description": "Cardiac Pacemaker Revision Except Device Replacement With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 41991.36, "minimum": 15891.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41991.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37534.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39183.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35301.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33117.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35077.23 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13375.93, "90th_percentile": 13375.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13375.93, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37272.66, "90th_percentile": 37272.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37272.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2090.95, "90th_percentile": 2090.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2090.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15209.93, "90th_percentile": 15209.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15209.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 17616.12, "90th_percentile": 17616.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17616.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15330.0, "90th_percentile": 15330.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15330.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "260", "type": "MS-DRG" } ], "description": "Cardiac Pacemaker Revision Except Device Replacement With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 75395.89, "minimum": 26471.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75395.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67393.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 70353.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63383.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59462.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26471.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62981.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24284.39, "90th_percentile": 26665.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24889.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 26146.82, "90th_percentile": 26146.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26146.82, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 62516.8, "90th_percentile": 62516.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62516.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24520.39, "90th_percentile": 24520.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24520.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26810.35, "90th_percentile": 26810.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26810.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 82720.58, "90th_percentile": 82720.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82720.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25022.83, "90th_percentile": 25133.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25022.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26012.58, "90th_percentile": 26012.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26012.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24480.38, "90th_percentile": 25950.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24513.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "259", "type": "MS-DRG" } ], "description": "Cardiac Pacemaker Device Replacement Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38897.45, "minimum": 16913.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38897.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34768.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36296.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32700.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30677.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16913.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32492.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33215.42, "90th_percentile": 33215.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33215.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14133.83, "90th_percentile": 14133.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14133.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13490.46, "90th_percentile": 13490.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13490.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "258", "type": "MS-DRG" } ], "description": "Cardiac Pacemaker Device Replacement With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 62086.31, "minimum": 25611.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62086.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 55496.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 57934.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52194.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48965.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25611.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 51863.43 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "257", "type": "MS-DRG" } ], "description": "Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19738.64, "minimum": 9692.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19738.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17643.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18418.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16593.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15567.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9692.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16488.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "256", "type": "MS-DRG" } ], "description": "Upper Limb And Toe Amputation For Circulatory System Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 37481.06, "minimum": 14396.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37481.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33502.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34974.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31509.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29560.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14396.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31309.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13648.02, "90th_percentile": 13648.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13648.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11512.49, "90th_percentile": 11512.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11512.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "255", "type": "MS-DRG" } ], "description": "Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 57901.34, "minimum": 22158.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57901.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51755.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 54029.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48676.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45664.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22158.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48367.54 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7951.72, "90th_percentile": 7951.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7951.72, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15944.13, "90th_percentile": 15944.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15944.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20212.09, "90th_percentile": 21484.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20212.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "254", "type": "MS-DRG" } ], "description": "Other Vascular Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38713.76, "minimum": 15046.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38713.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34604.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36124.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32545.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30532.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15046.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32339.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 41657.93, "90th_percentile": 41657.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41657.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13513.27, "90th_percentile": 14444.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13513.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34361.71, "90th_percentile": 255677.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34606.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14086.25, "90th_percentile": 14086.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14086.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13607.15, "90th_percentile": 14092.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14074.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38355.37, "90th_percentile": 38355.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38355.37, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13795.49, "90th_percentile": 14505.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13795.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36568.8, "90th_percentile": 36568.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36568.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "253", "type": "MS-DRG" } ], "description": "Other Vascular Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 56498.23, "minimum": 21367.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56498.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50501.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 52719.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47496.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44558.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21367.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47195.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 75007.47, "90th_percentile": 75007.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75007.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17896.09, "90th_percentile": 20757.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19596.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24931.15, "90th_percentile": 24931.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24931.15, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49988.52, "90th_percentile": 53124.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50146.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 15712.78, "90th_percentile": 15712.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15712.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17424.91, "90th_percentile": 20944.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19429.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 67079.25, "90th_percentile": 67079.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67079.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 20492.0, "90th_percentile": 20492.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20492.0, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 66815.96, "90th_percentile": 66815.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66815.96, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12935.93, "90th_percentile": 14863.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12935.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 88253.88, "90th_percentile": 88253.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 88253.88, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 19108.44, "90th_percentile": 19108.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19108.44, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 16420.57, "90th_percentile": 16420.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16420.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17980.17, "90th_percentile": 20498.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 20047.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 20199.38, "90th_percentile": 20376.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20199.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16420.57, "90th_percentile": 16420.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16420.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50594.83, "90th_percentile": 50594.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50594.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 18590.25, "90th_percentile": 18590.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18590.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18562.57, "90th_percentile": 21139.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19056.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44560.06, "90th_percentile": 73308.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45039.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "252", "type": "MS-DRG" } ], "description": "Other Vascular Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 75913.76, "minimum": 28300.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75913.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67856.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 70837.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63818.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59870.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28300.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63414.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 192428.4, "90th_percentile": 192428.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 192428.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24318.1, "90th_percentile": 26961.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24319.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 37410.17, "90th_percentile": 42906.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37410.17, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19604.27, "90th_percentile": 19604.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19604.27, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 72738.03, "90th_percentile": 289540.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72738.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26739.47, "90th_percentile": 26739.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26739.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 27308.11, "90th_percentile": 27308.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27308.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 35482.83, "90th_percentile": 172091.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36874.54, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 252177.73, "90th_percentile": 252177.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 252177.73, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 27235.64, "90th_percentile": 27235.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27235.64, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 14122.77, "90th_percentile": 14122.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14122.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24791.32, "90th_percentile": 110184.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26486.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 76198.06, "90th_percentile": 76198.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76198.06, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 26751.31, "90th_percentile": 26751.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26751.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19604.27, "90th_percentile": 19604.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19604.27, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26850.72, "90th_percentile": 27801.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26850.72, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25145.41, "90th_percentile": 27601.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27033.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "251", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34579.69, "minimum": 12816.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34579.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30909.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32267.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29070.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27271.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12816.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28885.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12696.05, "90th_percentile": 12696.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12696.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26270.43, "90th_percentile": 26270.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26270.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12431.87, "90th_percentile": 12431.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12431.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9706.15, "90th_percentile": 9706.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9706.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5599.37, "90th_percentile": 5599.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5599.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16487.56, "90th_percentile": 16487.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16487.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27621.62, "90th_percentile": 27621.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27621.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "250", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 51182.36, "minimum": 18159.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51182.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45749.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47759.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43027.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40365.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18159.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42754.88 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18329.17, "90th_percentile": 18329.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18329.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 45424.09, "90th_percentile": 45424.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45424.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18313.33, "90th_percentile": 18313.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18313.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 27170.93, "90th_percentile": 27170.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27170.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18074.45, "90th_percentile": 18074.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18074.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 18355.41, "90th_percentile": 18355.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18355.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 575.0, "90th_percentile": 575.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 575.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42685.97, "90th_percentile": 42685.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42685.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "245", "type": "MS-DRG" } ], "description": "Aicd Generator Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 108143.13, "minimum": 36641.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 108143.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 96664.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 100911.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90913.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85288.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36641.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 90336.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 34123.51, "90th_percentile": 34123.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34123.51, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "244", "type": "MS-DRG" } ], "description": "Permanent Cardiac Pacemaker Implant Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 39939.82, "minimum": 15247.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39939.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35700.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37268.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33576.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31499.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15247.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33363.49 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 202369.81, "90th_percentile": 202369.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 202369.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14491.07, "90th_percentile": 14822.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14501.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37631.6, "90th_percentile": 37631.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37631.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14195.66, "90th_percentile": 14490.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14195.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14086.03, "90th_percentile": 14618.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14503.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42156.48, "90th_percentile": 42156.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42156.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 1279.22, "90th_percentile": 1279.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1279.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 14508.31, "90th_percentile": 14508.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14508.31, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5496.61, "90th_percentile": 5496.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5496.61, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38365.34, "90th_percentile": 38365.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38365.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14625.54, "90th_percentile": 15005.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14629.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39673.66, "90th_percentile": 39673.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39673.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "243", "type": "MS-DRG" } ], "description": "Permanent Cardiac Pacemaker Implant With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 49854.5, "minimum": 17758.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49854.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44562.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46520.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41911.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39318.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17758.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41645.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 59076.53, "90th_percentile": 59076.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59076.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15591.09, "90th_percentile": 18765.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 16622.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 16832.82, "90th_percentile": 16832.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16832.82, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16281.36, "90th_percentile": 18010.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17458.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13503.25, "90th_percentile": 13503.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13503.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16084.09, "90th_percentile": 17929.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17866.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 19370.64, "90th_percentile": 19370.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19370.64, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17222.03, "90th_percentile": 18000.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17222.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 17866.3, "90th_percentile": 17866.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17866.3, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 47944.69, "90th_percentile": 47944.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47944.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 12684.07, "90th_percentile": 12684.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12684.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16563.05, "90th_percentile": 18160.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18045.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43679.54, "90th_percentile": 43679.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43679.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "242", "type": "MS-DRG" } ], "description": "Permanent Cardiac Pacemaker Implant With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 75068.35, "minimum": 26005.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75068.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67100.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 70048.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63108.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59203.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26005.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 62707.9 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19808.09, "90th_percentile": 26475.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 24072.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 81518.29, "90th_percentile": 81518.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 81518.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 25895.31, "90th_percentile": 25895.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25895.31, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22364.77, "90th_percentile": 26677.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24930.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23771.11, "90th_percentile": 26507.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 26459.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 39346.45, "90th_percentile": 39346.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39346.45, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 26461.71, "90th_percentile": 26461.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26461.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 24245.1, "90th_percentile": 24245.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24245.1, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 253551.51, "90th_percentile": 253551.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 253551.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21557.49, "90th_percentile": 26887.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25232.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "241", "type": "MS-DRG" } ], "description": "Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33413.38, "minimum": 11961.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33413.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29866.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31178.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28089.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26352.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11961.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27911.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27288.16, "90th_percentile": 27288.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27288.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "240", "type": "MS-DRG" } ], "description": "Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 64445.47, "minimum": 23347.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64445.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57605.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 60135.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54177.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50826.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23347.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53834.14 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 73055.08, "90th_percentile": 73055.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73055.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11541.94, "90th_percentile": 11541.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11541.94, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 57527.45, "90th_percentile": 57527.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57527.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15922.8, "90th_percentile": 22862.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21796.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 22566.99, "90th_percentile": 22566.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22566.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22848.11, "90th_percentile": 22848.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22848.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16086.0, "90th_percentile": 16086.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16086.0, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21130.04, "90th_percentile": 21130.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21130.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "239", "type": "MS-DRG" } ], "description": "Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 111462.78, "minimum": 39431.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 111462.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 99632.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 104008.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93704.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87907.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39431.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 93109.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35296.83, "90th_percentile": 95297.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38841.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 38031.9, "90th_percentile": 38031.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38031.9, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 62454.37, "90th_percentile": 62454.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62454.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36265.07, "90th_percentile": 61136.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38308.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 23434.79, "90th_percentile": 23434.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23434.79, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36708.14, "90th_percentile": 38866.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38705.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33878.07, "90th_percentile": 39219.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37661.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 92971.1, "90th_percentile": 92971.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 92971.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "236", "type": "MS-DRG" } ], "description": "Coronary Bypass Without Cardiac Catheterization Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 90998.25, "minimum": 33740.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90998.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 81339.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 84912.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76500.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71767.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33740.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 76014.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 144048.25, "90th_percentile": 171393.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 161850.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28995.7, "90th_percentile": 32140.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 31904.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23020.14, "90th_percentile": 23020.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23020.14, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 80769.87, "90th_percentile": 275660.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 235408.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 23314.74, "90th_percentile": 23314.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23314.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29314.6, "90th_percentile": 32029.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 30754.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 223485.95, "90th_percentile": 223485.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 223485.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 71290.93, "90th_percentile": 119649.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73215.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 22138.8, "90th_percentile": 22138.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22138.8, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 21972.42, "90th_percentile": 30233.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22381.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 170852.69, "90th_percentile": 170852.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 170852.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 151476.76, "90th_percentile": 151476.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 151476.76, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 33386.25, "90th_percentile": 33386.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33386.25, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 24274.29, "90th_percentile": 24274.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24274.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29305.26, "90th_percentile": 40883.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 31920.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 187068.41, "90th_percentile": 218162.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 203833.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 69592.39, "90th_percentile": 69592.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69592.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 31910.92, "90th_percentile": 32145.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31913.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 41036.23, "90th_percentile": 41036.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41036.23, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23020.14, "90th_percentile": 24274.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23020.14, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 158102.77, "90th_percentile": 172611.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 159313.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 21829.45, "90th_percentile": 23018.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21829.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30127.96, "90th_percentile": 32182.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 32161.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 149908.28, "90th_percentile": 222879.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 180895.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "235", "type": "MS-DRG" } ], "description": "Coronary Bypass Without Cardiac Catheterization With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 130214.38, "minimum": 46785.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 130214.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 116393.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 121506.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 109468.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102695.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46785.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 108773.81 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 164556.83, "90th_percentile": 193980.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 168542.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38351.67, "90th_percentile": 45426.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43184.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 4198.35, "90th_percentile": 4198.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4198.35, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29284.61, "90th_percentile": 46191.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29284.61, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 208813.85, "90th_percentile": 289601.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 243320.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 28022.34, "90th_percentile": 28022.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28022.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38916.8, "90th_percentile": 45391.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 44289.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 71621.21, "90th_percentile": 138649.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79620.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 60604.78, "90th_percentile": 60604.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60604.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 202488.73, "90th_percentile": 202488.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 202488.73, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 180798.35, "90th_percentile": 217668.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 180798.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 44070.67, "90th_percentile": 44070.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44070.67, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25600.0, "90th_percentile": 25600.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25600.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40906.53, "90th_percentile": 63270.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 43325.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 194176.89, "90th_percentile": 503057.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 215111.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 41119.09, "90th_percentile": 45269.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41119.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 4198.35, "90th_percentile": 4198.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4198.35, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33400.7, "90th_percentile": 33400.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33400.7, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 215741.41, "90th_percentile": 215741.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 215741.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 40422.34, "90th_percentile": 40422.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40422.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43634.37, "90th_percentile": 46303.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 45638.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 160586.45, "90th_percentile": 224843.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 205359.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "234", "type": "MS-DRG" } ], "description": "Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 117734.71, "minimum": 43632.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117734.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 105238.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 109861.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 98976.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92853.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43632.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 98348.99 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 196171.95, "90th_percentile": 196171.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 196171.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40072.81, "90th_percentile": 43419.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41299.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 224803.45, "90th_percentile": 263563.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 249550.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34467.14, "90th_percentile": 41124.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38275.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 26507.62, "90th_percentile": 26507.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26507.62, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 36193.07, "90th_percentile": 36193.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36193.07, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 28264.55, "90th_percentile": 28264.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28264.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30643.6, "90th_percentile": 41028.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30730.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 215666.66, "90th_percentile": 215666.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 215666.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 93002.73, "90th_percentile": 93002.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 93002.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 41162.34, "90th_percentile": 41926.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41162.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28264.55, "90th_percentile": 28264.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28264.55, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37079.21, "90th_percentile": 37079.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37079.21, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 205828.08, "90th_percentile": 205828.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 205828.08, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 217890.8, "90th_percentile": 231265.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 220660.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34168.15, "90th_percentile": 42809.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39511.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 194609.53, "90th_percentile": 194609.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 194609.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "233", "type": "MS-DRG" } ], "description": "Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 172971.47, "minimum": 60581.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 172971.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 154612.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 161404.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 145412.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 136416.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60581.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 144490.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 253825.11, "90th_percentile": 306600.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 253825.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42624.16, "90th_percentile": 57756.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 52860.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 308747.01, "90th_percentile": 308747.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 308747.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 266672.5, "90th_percentile": 276454.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 266672.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 57702.32, "90th_percentile": 58254.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58087.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 110081.85, "90th_percentile": 110081.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110081.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 30151.33, "90th_percentile": 30151.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30151.33, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 58687.04, "90th_percentile": 58687.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58687.04, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 42717.86, "90th_percentile": 42717.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42717.86, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46166.91, "90th_percentile": 57574.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54307.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 286870.59, "90th_percentile": 313522.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 286870.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 57393.32, "90th_percentile": 59802.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57839.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 62209.74, "90th_percentile": 62209.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62209.74, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 196307.69, "90th_percentile": 196307.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 196307.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60549.71, "90th_percentile": 60549.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60549.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 245873.11, "90th_percentile": 245873.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 245873.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "232", "type": "MS-DRG" } ], "description": "Coronary Bypass With Ptca Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 135182.79, "minimum": 48291.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 135182.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 120834.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 126142.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113644.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106614.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48291.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 112924.14 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 262245.85, "90th_percentile": 262245.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 262245.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 45539.11, "90th_percentile": 45539.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45539.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "231", "type": "MS-DRG" } ], "description": "Coronary Bypass With Ptca With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 187524.82, "minimum": 66675.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 187524.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 167620.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 174984.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 157647.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147894.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 66675.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 156647.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 23960.91, "90th_percentile": 23960.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23960.91, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 236096.15, "90th_percentile": 236096.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 236096.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "229", "type": "MS-DRG" } ], "description": "Other Cardiothoracic Procedures Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 68741.1, "minimum": 25669.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68741.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 61444.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 64144.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57788.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54213.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25669.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57422.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 73638.46, "90th_percentile": 73638.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73638.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24325.29, "90th_percentile": 32187.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24325.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 267623.8, "90th_percentile": 267623.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 267623.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10762.74, "90th_percentile": 10762.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10762.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24390.25, "90th_percentile": 39554.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24390.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 14403.47, "90th_percentile": 14403.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14403.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 18051.78, "90th_percentile": 27558.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18051.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22089.64, "90th_percentile": 38060.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23322.47, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 65729.21, "90th_percentile": 72730.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65729.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 37632.63, "90th_percentile": 37632.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37632.63, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 23640.27, "90th_percentile": 23640.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23640.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15008.54, "90th_percentile": 15008.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15008.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 83445.69, "90th_percentile": 83445.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83445.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13535.09, "90th_percentile": 13535.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13535.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24544.13, "90th_percentile": 25395.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24598.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 78166.5, "90th_percentile": 78166.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78166.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "228", "type": "MS-DRG" } ], "description": "Other Cardiothoracic Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 110276.56, "minimum": 39631.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110276.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 98571.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 102901.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92706.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86971.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39631.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92118.87 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3539.33, "90th_percentile": 38581.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37768.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32773.29, "90th_percentile": 32773.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32773.29, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37590.64, "90th_percentile": 37590.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37590.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16396.16, "90th_percentile": 16396.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16396.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38341.53, "90th_percentile": 38732.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38576.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 40268.29, "90th_percentile": 40268.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40268.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39900.54, "90th_percentile": 39900.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39900.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 21852.03, "90th_percentile": 21852.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21852.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36778.53, "90th_percentile": 39208.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38794.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "221", "type": "MS-DRG" } ], "description": "Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M", "standard_charges": [ { "billing_class": "facility", "maximum": 101632.19, "minimum": 40351.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101632.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 90844.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 94835.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85439.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80154.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40351.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 84897.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38883.67, "90th_percentile": 38883.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38883.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 66194.25, "90th_percentile": 66194.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66194.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "220", "type": "MS-DRG" } ], "description": "Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 117212.42, "minimum": 42624.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117212.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 104771.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 109373.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 98537.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92441.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42624.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 97912.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 152665.94, "90th_percentile": 208912.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 168119.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37083.88, "90th_percentile": 40865.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 38939.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 133574.71, "90th_percentile": 133574.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 133574.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 42926.7, "90th_percentile": 42926.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42926.7, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29671.52, "90th_percentile": 29671.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29671.52, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 104324.98, "90th_percentile": 346924.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 238219.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38485.42, "90th_percentile": 72629.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39289.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 80307.89, "90th_percentile": 80307.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80307.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 28648.37, "90th_percentile": 28648.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28648.37, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 26857.85, "90th_percentile": 64932.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26857.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 261283.08, "90th_percentile": 261283.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 261283.08, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 177390.31, "90th_percentile": 177390.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 177390.31, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 41817.03, "90th_percentile": 85991.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41817.03, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 29671.52, "90th_percentile": 29671.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29671.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38684.98, "90th_percentile": 72075.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40850.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 110223.93, "90th_percentile": 280973.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 221219.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 68453.53, "90th_percentile": 68453.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68453.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 42087.21, "90th_percentile": 44074.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42087.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26986.82, "90th_percentile": 29671.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26986.82, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40666.68, "90th_percentile": 40666.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40666.68, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 172205.45, "90th_percentile": 172205.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 172205.45, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 166638.88, "90th_percentile": 257059.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 222263.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39948.26, "90th_percentile": 51759.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40670.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 152661.62, "90th_percentile": 243070.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 193599.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "219", "type": "MS-DRG" } ], "description": "Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 171227.55, "minimum": 60838.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 171227.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 153053.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 159776.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 143946.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 135041.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60838.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 143033.92 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 353443.78, "90th_percentile": 353443.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 353443.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 53712.81, "90th_percentile": 80925.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 58172.57, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38396.43, "90th_percentile": 38396.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38396.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 59157.77, "90th_percentile": 59157.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59157.77, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32704.67, "90th_percentile": 32704.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32704.67, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 222269.3, "90th_percentile": 552924.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 306375.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 52661.88, "90th_percentile": 133839.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59233.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 135779.48, "90th_percentile": 135779.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 135779.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 82464.62, "90th_percentile": 82464.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82464.62, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 26857.85, "90th_percentile": 34837.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32691.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 202683.87, "90th_percentile": 202683.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 202683.87, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 341588.35, "90th_percentile": 341588.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 341588.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 53633.96, "90th_percentile": 60291.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53633.96, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 21703.97, "90th_percentile": 21703.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21703.97, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 52240.45, "90th_percentile": 74954.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 57658.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 159375.78, "90th_percentile": 473062.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 240650.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 57542.79, "90th_percentile": 59274.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57542.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 5492.99, "90th_percentile": 5492.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5492.99, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 211657.47, "90th_percentile": 303859.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 211657.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 72362.9, "90th_percentile": 72362.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72362.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 56248.08, "90th_percentile": 130078.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 59771.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 264984.62, "90th_percentile": 471610.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 295899.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "218", "type": "MS-DRG" } ], "description": "Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 131659.53, "minimum": 52273.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131659.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 117685.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 122854.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110683.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 103835.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109981.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 36294.26, "90th_percentile": 36294.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36294.26, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "217", "type": "MS-DRG" } ], "description": "Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 142908.72, "minimum": 52273.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 142908.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 127740.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 133351.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 120139.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112707.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52273.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 119377.95 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 52012.36, "90th_percentile": 52012.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52012.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 210649.15, "90th_percentile": 210649.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 210649.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49583.68, "90th_percentile": 49583.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49583.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 98222.02, "90th_percentile": 98222.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 98222.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 204730.77, "90th_percentile": 204730.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 204730.77, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 79880.99, "90th_percentile": 80825.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79880.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4703.91, "90th_percentile": 4703.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4703.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "216", "type": "MS-DRG" } ], "description": "Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 213573.0, "minimum": 77181.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 213573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 190904.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 199290.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 179545.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 168438.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77181.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 178406.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 64298.27, "90th_percentile": 74984.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71547.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 269889.75, "90th_percentile": 269889.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 269889.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 44276.19, "90th_percentile": 44276.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44276.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 72178.11, "90th_percentile": 112128.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73665.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 52627.64, "90th_percentile": 52627.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52627.64, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 32429.55, "90th_percentile": 32429.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32429.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 337690.85, "90th_percentile": 337690.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 337690.85, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 221564.24, "90th_percentile": 221564.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 221564.24, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 72879.5, "90th_percentile": 72879.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72879.5, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 75671.21, "90th_percentile": 112167.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80828.59, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 247948.28, "90th_percentile": 247948.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 247948.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 75303.18, "90th_percentile": 75303.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75303.18, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 52806.04, "90th_percentile": 52806.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52806.04, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 347710.92, "90th_percentile": 347710.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 347710.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 40027.42, "90th_percentile": 40027.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40027.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 70573.06, "90th_percentile": 76357.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74338.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "215", "type": "MS-DRG" } ], "description": "Other Heart Assist System Implant", "standard_charges": [ { "billing_class": "facility", "maximum": 234460.24, "minimum": 78534.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 234460.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 209574.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 218780.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 197105.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 184911.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78534.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 195854.98 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 75563.8, "90th_percentile": 75563.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75563.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 552750.75, "90th_percentile": 552750.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 552750.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 85860.86, "90th_percentile": 85860.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85860.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 67153.39, "90th_percentile": 67153.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67153.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 54288.98, "90th_percentile": 54288.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54288.98, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 237930.52, "90th_percentile": 237930.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 237930.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 241443.43, "90th_percentile": 241443.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 241443.43, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 79489.0, "90th_percentile": 79489.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79489.0, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 444223.26, "90th_percentile": 784048.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 444223.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 934772.22, "90th_percentile": 934772.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 934772.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 80522.69, "90th_percentile": 80522.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80522.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 370308.96, "90th_percentile": 370308.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 370308.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "212", "type": "MS-DRG" } ], "description": "Concomitant Aortic And Mitral Valve Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 241075.2, "minimum": 85656.82, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 241075.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 215487.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 224953.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 202666.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 190128.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 85656.82 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 201380.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 299343.43, "90th_percentile": 299343.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 299343.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 82151.96, "90th_percentile": 82151.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82151.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 7721.92, "90th_percentile": 7721.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7721.92, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 408002.3, "90th_percentile": 408002.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 408002.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 83038.3, "90th_percentile": 83038.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83038.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "208", "type": "MS-DRG" } ], "description": "Respiratory System Diagnosis With Ventilator Support <=96 Hours", "standard_charges": [ { "billing_class": "facility", "maximum": 59401.82, "minimum": 22556.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59401.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53096.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 55429.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49937.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46848.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22556.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49620.96 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 60158.03, "90th_percentile": 69098.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60158.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18449.82, "90th_percentile": 21305.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 19611.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36867.25, "90th_percentile": 36867.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36867.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15097.03, "90th_percentile": 15097.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15097.03, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25445.56, "90th_percentile": 394503.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52715.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 14533.05, "90th_percentile": 14533.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14533.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19055.5, "90th_percentile": 22114.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20195.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 21543.25, "90th_percentile": 21543.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21543.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10865.94, "90th_percentile": 10865.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10865.94, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3760.17, "90th_percentile": 13665.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10875.43, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 27842.55, "90th_percentile": 27842.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27842.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 20613.14, "90th_percentile": 20613.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20613.14, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19441.26, "90th_percentile": 21462.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20654.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 18846.13, "90th_percentile": 18846.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18846.13, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 20836.55, "90th_percentile": 21120.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20836.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14307.65, "90th_percentile": 15187.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15097.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21889.58, "90th_percentile": 21889.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21889.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10967.23, "90th_percentile": 10967.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10967.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19388.39, "90th_percentile": 21374.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20123.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46843.05, "90th_percentile": 49537.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46843.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "207", "type": "MS-DRG" } ], "description": "Respiratory System Diagnosis With Ventilator Support >96 Hours", "standard_charges": [ { "billing_class": "facility", "maximum": 143136.67, "minimum": 51181.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 143136.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 127944.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 133564.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 120331.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 112887.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51181.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 119568.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 142989.79, "90th_percentile": 142989.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 142989.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23500.57, "90th_percentile": 48530.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45047.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 23911.54, "90th_percentile": 23911.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23911.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47504.87, "90th_percentile": 49653.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47989.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 23819.12, "90th_percentile": 23819.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23819.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 42716.86, "90th_percentile": 43292.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42716.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 29406.13, "90th_percentile": 29406.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29406.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47367.27, "90th_percentile": 52284.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47512.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 119479.05, "90th_percentile": 119479.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 119479.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 47889.75, "90th_percentile": 52809.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47889.75, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 111367.12, "90th_percentile": 111367.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 111367.12, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 157141.29, "90th_percentile": 157141.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 157141.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 42075.35, "90th_percentile": 42075.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42075.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50251.71, "90th_percentile": 54495.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50251.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 113024.99, "90th_percentile": 113024.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 113024.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "206", "type": "MS-DRG" } ], "description": "Other Respiratory System Diagnoses Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20046.26, "minimum": 8519.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20046.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17918.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18705.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16852.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15809.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8519.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16745.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18887.74, "90th_percentile": 18887.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18887.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7719.65, "90th_percentile": 7852.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7730.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7117.11, "90th_percentile": 7117.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7117.11, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19687.56, "90th_percentile": 19687.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19687.56, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7711.72, "90th_percentile": 7711.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7711.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 673.26, "90th_percentile": 673.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 673.26, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8047.26, "90th_percentile": 8047.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8047.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17370.82, "90th_percentile": 17370.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17370.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "205", "type": "MS-DRG" } ], "description": "Other Respiratory System Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41776.69, "minimum": 15429.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41776.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37342.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38982.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35120.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32947.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15429.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34897.91 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13779.64, "90th_percentile": 15117.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13779.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37722.26, "90th_percentile": 37722.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37722.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14706.93, "90th_percentile": 15026.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14706.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 29104.26, "90th_percentile": 29104.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29104.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8390.69, "90th_percentile": 8390.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8390.69, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7063.63, "90th_percentile": 12950.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7063.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8834.33, "90th_percentile": 8834.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8834.33, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12969.73, "90th_percentile": 15154.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14989.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37036.75, "90th_percentile": 37036.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37036.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34845.01, "90th_percentile": 34845.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34845.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "204", "type": "MS-DRG" } ], "description": "Respiratory Signs And Symptoms", "standard_charges": [ { "billing_class": "facility", "maximum": 17946.03, "minimum": 7480.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17946.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16041.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16745.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15086.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14153.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7480.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14991.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16548.02, "90th_percentile": 16548.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16548.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5865.05, "90th_percentile": 6165.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5865.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14330.1, "90th_percentile": 14330.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14330.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4674.98, "90th_percentile": 4674.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4674.98, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50298.88, "90th_percentile": 50298.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50298.88, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7058.21, "90th_percentile": 7065.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7058.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "203", "type": "MS-DRG" } ], "description": "Bronchitis And Asthma Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15409.82, "minimum": 6413.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15409.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13774.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14379.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12954.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12153.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6413.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12872.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "202", "type": "MS-DRG" } ], "description": "Bronchitis And Asthma With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21394.04, "minimum": 8752.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21394.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19123.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19963.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17985.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16872.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8752.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17871.38 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20577.27, "90th_percentile": 20577.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20577.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6098.49, "90th_percentile": 8213.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8194.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6354.12, "90th_percentile": 6354.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6354.12, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20008.66, "90th_percentile": 20008.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20008.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7259.7, "90th_percentile": 8177.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8171.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6428.32, "90th_percentile": 6428.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6428.32, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7912.51, "90th_percentile": 8171.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7912.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9826.92, "90th_percentile": 9826.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9826.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5435.49, "90th_percentile": 6026.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5435.49, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7066.78, "90th_percentile": 7066.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7066.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "201", "type": "MS-DRG" } ], "description": "Pneumothorax Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14980.47, "minimum": 6763.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14980.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13390.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13978.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12593.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11814.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6763.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12513.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13044.73, "90th_percentile": 13044.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13044.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13299.6, "90th_percentile": 13394.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13394.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4624.5, "90th_percentile": 4624.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4624.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9713.46, "90th_percentile": 9713.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9713.46, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 34316.01, "90th_percentile": 34316.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34316.01, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "200", "type": "MS-DRG" } ], "description": "Pneumothorax With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 24507.87, "minimum": 9747.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24507.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21906.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22868.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20603.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19328.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9747.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20472.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 25702.73, "90th_percentile": 25702.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25702.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9239.94, "90th_percentile": 9522.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9263.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21321.32, "90th_percentile": 22647.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21753.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5751.57, "90th_percentile": 5751.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5751.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7651.52, "90th_percentile": 7651.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7651.52, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9260.47, "90th_percentile": 9260.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9260.47, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20125.74, "90th_percentile": 20125.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20125.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9273.47, "90th_percentile": 9273.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9273.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6354.12, "90th_percentile": 6354.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6354.12, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7386.98, "90th_percentile": 7386.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7386.98, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17333.58, "90th_percentile": 17333.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17333.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8582.35, "90th_percentile": 9323.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8582.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "199", "type": "MS-DRG" } ], "description": "Pneumothorax With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 39065.64, "minimum": 14910.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39065.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34919.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36453.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32841.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30809.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14910.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32633.25 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12953.2, "90th_percentile": 13166.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12953.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34481.16, "90th_percentile": 34481.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34481.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7554.03, "90th_percentile": 7554.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7554.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7996.59, "90th_percentile": 7996.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7996.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13783.39, "90th_percentile": 14617.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14237.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9257.56, "90th_percentile": 9257.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9257.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32583.91, "90th_percentile": 32583.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32583.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "198", "type": "MS-DRG" } ], "description": "Interstitial Lung Disease Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15500.55, "minimum": 6772.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15500.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13855.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14463.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13030.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12224.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6772.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12948.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "197", "type": "MS-DRG" } ], "description": "Interstitial Lung Disease With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 21907.48, "minimum": 8581.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21907.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19582.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20442.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18417.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17277.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8581.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18300.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8353.16, "90th_percentile": 8353.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8353.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30857.69, "90th_percentile": 30857.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30857.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "196", "type": "MS-DRG" } ], "description": "Interstitial Lung Disease With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41699.23, "minimum": 15866.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41699.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37273.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38910.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35055.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32886.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15866.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34833.21 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 28120.5, "90th_percentile": 28120.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28120.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11398.78, "90th_percentile": 13785.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12798.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12774.95, "90th_percentile": 14205.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13693.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 34044.06, "90th_percentile": 34044.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34044.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10116.35, "90th_percentile": 10116.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10116.35, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6054.42, "90th_percentile": 7433.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6054.42, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15227.23, "90th_percentile": 15227.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15227.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 40950.91, "90th_percentile": 40950.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40950.91, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 9412.07, "90th_percentile": 9412.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9412.07, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12829.14, "90th_percentile": 15176.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14390.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15639.85, "90th_percentile": 15639.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15639.85, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7701.75, "90th_percentile": 7701.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7701.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6796.53, "90th_percentile": 15353.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13642.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29640.13, "90th_percentile": 29640.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29640.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "195", "type": "MS-DRG" } ], "description": "Simple Pneumonia And Pleurisy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 13783.19, "minimum": 6091.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13783.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12320.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12861.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11587.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10870.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6091.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11513.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11057.66, "90th_percentile": 11057.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11057.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5252.55, "90th_percentile": 5252.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5252.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3927.87, "90th_percentile": 3927.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3927.87, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4339.36, "90th_percentile": 4339.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4339.36, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5016.0, "90th_percentile": 6587.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5016.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10969.36, "90th_percentile": 10969.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10969.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "194", "type": "MS-DRG" } ], "description": "Simple Pneumonia And Pleurisy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 18147.42, "minimum": 7469.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18147.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16221.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16933.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15256.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14312.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7469.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15159.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15109.16, "90th_percentile": 15109.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15109.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5182.23, "90th_percentile": 8250.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7080.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9815.1, "90th_percentile": 9815.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9815.1, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16106.44, "90th_percentile": 16804.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16106.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5043.87, "90th_percentile": 5043.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5043.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7083.26, "90th_percentile": 7125.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7083.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8592.87, "90th_percentile": 8592.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8592.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4316.83, "90th_percentile": 4316.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4316.83, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4771.23, "90th_percentile": 4771.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4771.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 6389.69, "90th_percentile": 6389.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6389.69, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4994.37, "90th_percentile": 4994.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4994.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5115.14, "90th_percentile": 7322.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6829.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15573.27, "90th_percentile": 15573.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15573.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7098.61, "90th_percentile": 7098.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7098.61, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14312.28, "90th_percentile": 14312.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14312.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6575.43, "90th_percentile": 6575.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6575.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5368.2, "90th_percentile": 7939.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 6597.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14312.28, "90th_percentile": 15135.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14312.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "193", "type": "MS-DRG" } ], "description": "Simple Pneumonia And Pleurisy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29164.23, "minimum": 11417.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29164.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26068.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27213.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24517.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23000.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11417.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24362.17 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29134.35, "90th_percentile": 29162.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29134.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8094.76, "90th_percentile": 10829.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 9877.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 11497.55, "90th_percentile": 11497.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11497.55, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10970.15, "90th_percentile": 14868.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10970.15, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13896.88, "90th_percentile": 27476.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25882.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10497.3, "90th_percentile": 10497.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10497.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8721.71, "90th_percentile": 10908.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 10556.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 14759.43, "90th_percentile": 14759.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14759.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5195.79, "90th_percentile": 9058.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5678.78, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4771.23, "90th_percentile": 9929.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6276.54, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10916.97, "90th_percentile": 10916.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10916.97, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5271.07, "90th_percentile": 6934.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5271.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8670.21, "90th_percentile": 10864.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 10093.24, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25851.96, "90th_percentile": 25851.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25851.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 15654.71, "90th_percentile": 15654.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15654.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10844.12, "90th_percentile": 10844.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10844.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10627.37, "90th_percentile": 10851.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10825.03, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5181.09, "90th_percentile": 6934.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6934.09, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 934.03, "90th_percentile": 11208.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8636.98, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19287.8, "90th_percentile": 19287.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19287.8, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22999.14, "90th_percentile": 22999.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22999.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4998.43, "90th_percentile": 6575.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4998.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8883.47, "90th_percentile": 10952.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 10098.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21455.15, "90th_percentile": 22999.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22867.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "192", "type": "MS-DRG" } ], "description": "Chronic Obstructive Pulmonary Disease Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14323.18, "minimum": 6196.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14323.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12802.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13365.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12041.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11296.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6196.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11964.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "191", "type": "MS-DRG" } ], "description": "Chronic Obstructive Pulmonary Disease With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 19012.74, "minimum": 7757.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19012.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16994.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17741.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15983.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14994.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7757.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15882.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7085.26, "90th_percentile": 7299.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7085.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17578.24, "90th_percentile": 17578.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17578.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5779.74, "90th_percentile": 5779.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5779.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5225.16, "90th_percentile": 5225.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5225.16, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4361.03, "90th_percentile": 4361.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4361.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7359.5, "90th_percentile": 7604.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7401.2, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5987.04, "90th_percentile": 5987.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5987.04, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3745.72, "90th_percentile": 14531.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6446.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "190", "type": "MS-DRG" } ], "description": "Chronic Obstructive Pulmonary Disease With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24859.75, "minimum": 9812.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24859.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22221.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23197.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20899.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19606.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9812.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20766.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7271.59, "90th_percentile": 9427.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9361.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7707.27, "90th_percentile": 9410.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8499.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4101.33, "90th_percentile": 4101.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4101.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5165.51, "90th_percentile": 5165.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5165.51, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5709.25, "90th_percentile": 16690.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5709.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 23408.41, "90th_percentile": 23408.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23408.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6485.54, "90th_percentile": 9258.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7390.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8391.22, "90th_percentile": 8391.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8391.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7877.21, "90th_percentile": 9619.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8185.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "189", "type": "MS-DRG" } ], "description": "Pulmonary Edema And Respiratory Failure", "standard_charges": [ { "billing_class": "facility", "maximum": 27387.11, "minimum": 10804.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27387.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24480.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25555.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23023.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21599.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10804.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22877.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7262.9, "90th_percentile": 10287.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 9343.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28438.54, "90th_percentile": 28438.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28438.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19872.85, "90th_percentile": 25451.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24305.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6402.74, "90th_percentile": 6402.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6402.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7688.7, "90th_percentile": 10279.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 9634.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8808.86, "90th_percentile": 8808.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8808.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4244.77, "90th_percentile": 4244.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4244.77, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5892.26, "90th_percentile": 13665.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 6056.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 20000.8, "90th_percentile": 20000.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20000.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8603.23, "90th_percentile": 8603.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8603.23, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6691.15, "90th_percentile": 6781.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6691.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8066.93, "90th_percentile": 10592.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 9611.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18965.69, "90th_percentile": 24967.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20682.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9335.42, "90th_percentile": 10232.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9924.87, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10227.92, "90th_percentile": 11335.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10227.92, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5768.23, "90th_percentile": 15187.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6781.81, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10581.5, "90th_percentile": 10879.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10581.5, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19629.61, "90th_percentile": 19629.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19629.61, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21597.58, "90th_percentile": 21597.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21597.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6345.05, "90th_percentile": 9228.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9228.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8272.39, "90th_percentile": 10591.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 8680.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18779.46, "90th_percentile": 21597.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21135.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "188", "type": "MS-DRG" } ], "description": "Pleural Effusion Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16246.37, "minimum": 6780.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16246.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14521.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15159.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13657.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12812.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6780.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13571.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14523.94, "90th_percentile": 14523.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14523.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6039.44, "90th_percentile": 6039.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6039.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14404.27, "90th_percentile": 14404.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14404.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "187", "type": "MS-DRG" } ], "description": "Pleural Effusion With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22217.31, "minimum": 8891.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22217.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19859.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20731.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18677.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17522.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8891.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18559.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 711.67, "90th_percentile": 8452.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 711.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8348.52, "90th_percentile": 8348.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8348.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5751.57, "90th_percentile": 5751.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5751.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6649.12, "90th_percentile": 8452.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8311.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19051.39, "90th_percentile": 19051.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19051.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 711.67, "90th_percentile": 711.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 711.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18531.83, "90th_percentile": 18531.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18531.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8547.73, "90th_percentile": 8547.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8547.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "186", "type": "MS-DRG" } ], "description": "Pleural Effusion With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34966.98, "minimum": 13313.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34966.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31255.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32628.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29395.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27577.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13313.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29209.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12800.5, "90th_percentile": 12800.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12800.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32946.16, "90th_percentile": 32946.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32946.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8453.54, "90th_percentile": 8453.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8453.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11676.75, "90th_percentile": 11809.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11731.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 37523.41, "90th_percentile": 37523.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37523.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 87162.14, "90th_percentile": 87162.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 87162.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7034.95, "90th_percentile": 7034.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7034.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8769.43, "90th_percentile": 8769.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8769.43, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8160.97, "90th_percentile": 8160.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8160.97, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10987.6, "90th_percentile": 12872.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11759.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24322.65, "90th_percentile": 24322.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24322.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 14229.27, "90th_percentile": 14229.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14229.27, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6025.46, "90th_percentile": 6025.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6025.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11971.66, "90th_percentile": 11971.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11971.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26859.63, "90th_percentile": 26859.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26859.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "185", "type": "MS-DRG" } ], "description": "Major Chest Trauma Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17209.07, "minimum": 7318.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17209.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15382.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16058.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14467.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13572.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7318.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14375.49 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16915.26, "90th_percentile": 16915.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16915.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6674.26, "90th_percentile": 6674.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6674.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6453.87, "90th_percentile": 6453.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6453.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6745.65, "90th_percentile": 6745.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6745.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5705.18, "90th_percentile": 5705.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5705.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "184", "type": "MS-DRG" } ], "description": "Major Chest Trauma With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23635.91, "minimum": 9474.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23635.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21127.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22055.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19870.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18640.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9474.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19744.12 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7293.43, "90th_percentile": 8942.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7891.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21129.15, "90th_percentile": 21129.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21129.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7554.03, "90th_percentile": 7554.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7554.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7249.43, "90th_percentile": 8972.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8900.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 38036.07, "90th_percentile": 38036.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38036.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3758.2, "90th_percentile": 3758.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3758.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 13465.03, "90th_percentile": 13465.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13465.03, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7803.63, "90th_percentile": 7803.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7803.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8470.23, "90th_percentile": 8941.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8470.23, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8939.67, "90th_percentile": 8939.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8939.67, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8027.71, "90th_percentile": 9043.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9017.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19714.99, "90th_percentile": 19714.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19714.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "183", "type": "MS-DRG" } ], "description": "Major Chest Trauma With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35126.32, "minimum": 13091.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35126.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31397.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32777.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29529.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27702.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29342.57 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11283.53, "90th_percentile": 12893.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11726.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31399.97, "90th_percentile": 31399.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31399.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5260.94, "90th_percentile": 5260.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5260.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11288.17, "90th_percentile": 12974.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11728.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7063.63, "90th_percentile": 10186.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7063.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11405.35, "90th_percentile": 11405.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11405.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10932.71, "90th_percentile": 10932.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10932.71, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11230.95, "90th_percentile": 12870.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12505.28, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30015.11, "90th_percentile": 30015.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30015.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11728.35, "90th_percentile": 14524.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11728.35, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13031.84, "90th_percentile": 13031.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13031.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23035.37, "90th_percentile": 23035.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23035.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "182", "type": "MS-DRG" } ], "description": "Respiratory Neoplasms Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18534.71, "minimum": 7064.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18534.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16567.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17295.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15581.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14617.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7064.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15482.86 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6957.1, "90th_percentile": 6957.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6957.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "181", "type": "MS-DRG" } ], "description": "Respiratory Neoplasms With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 24569.84, "minimum": 9527.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24569.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21961.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22926.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20655.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19377.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20524.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8500.06, "90th_percentile": 8500.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8500.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 9376.64, "90th_percentile": 9376.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9376.64, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8751.1, "90th_percentile": 8751.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8751.1, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7685.99, "90th_percentile": 9314.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9297.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6867.83, "90th_percentile": 6867.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6867.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20493.92, "90th_percentile": 20493.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20493.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9338.67, "90th_percentile": 9338.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9338.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "180", "type": "MS-DRG" } ], "description": "Respiratory Neoplasms With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38678.35, "minimum": 14925.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38678.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34573.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36091.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32515.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30504.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14925.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32309.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 41290.85, "90th_percentile": 41290.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41290.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11279.1, "90th_percentile": 14167.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 14061.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38680.56, "90th_percentile": 38680.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38680.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22095.1, "90th_percentile": 34574.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34330.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11592.89, "90th_percentile": 14498.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 12276.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8998.57, "90th_percentile": 8998.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8998.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8751.1, "90th_percentile": 8751.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8751.1, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11911.69, "90th_percentile": 14092.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 12378.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 12150.78, "90th_percentile": 12150.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12150.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9667.88, "90th_percentile": 9667.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9667.88, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32446.83, "90th_percentile": 32446.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32446.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6512.59, "90th_percentile": 6512.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6512.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12279.01, "90th_percentile": 14285.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14212.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32260.89, "90th_percentile": 32260.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32260.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "179", "type": "MS-DRG" } ], "description": "Respiratory Infections And Inflammations Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17034.23, "minimum": 7073.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17034.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15226.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15895.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14320.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13434.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7073.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14229.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6700.89, "90th_percentile": 6700.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6700.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 1006.39, "90th_percentile": 1006.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1006.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11412.25, "90th_percentile": 11412.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11412.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5184.42, "90th_percentile": 5184.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5184.42, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "178", "type": "MS-DRG" } ], "description": "Respiratory Infections And Inflammations With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 21956.17, "minimum": 8790.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21956.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19625.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20487.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18458.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17316.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8790.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18340.95 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16931.09, "90th_percentile": 16931.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16931.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6524.08, "90th_percentile": 6524.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6524.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19486.83, "90th_percentile": 19625.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19486.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8385.19, "90th_percentile": 8385.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8385.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5688.16, "90th_percentile": 5688.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5688.16, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6286.92, "90th_percentile": 6286.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6286.92, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6397.57, "90th_percentile": 8401.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6915.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7692.0, "90th_percentile": 7692.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7692.0, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8879.27, "90th_percentile": 8879.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8879.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15501.97, "90th_percentile": 15501.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15501.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "177", "type": "MS-DRG" } ], "description": "Respiratory Infections And Inflammations With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35774.76, "minimum": 13346.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35774.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31977.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33382.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30074.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28214.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13346.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29884.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 35740.82, "90th_percentile": 37795.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35740.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7665.77, "90th_percentile": 13108.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 11917.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 11845.81, "90th_percentile": 11845.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11845.81, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27613.28, "90th_percentile": 31977.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29957.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9618.15, "90th_percentile": 13108.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 11481.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 15837.62, "90th_percentile": 15837.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15837.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6388.79, "90th_percentile": 6388.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6388.79, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6979.22, "90th_percentile": 25960.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7061.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 33965.28, "90th_percentile": 33965.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33965.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7710.38, "90th_percentile": 7710.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7710.38, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8871.56, "90th_percentile": 13071.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 10930.26, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31714.11, "90th_percentile": 31714.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31714.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 11155.26, "90th_percentile": 11796.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11155.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13559.72, "90th_percentile": 13559.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13559.72, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7710.38, "90th_percentile": 7710.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7710.38, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11920.73, "90th_percentile": 13548.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13542.92, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11393.31, "90th_percentile": 11393.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11393.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11049.86, "90th_percentile": 13208.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 11720.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28214.39, "90th_percentile": 28214.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28214.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "176", "type": "MS-DRG" } ], "description": "Pulmonary Embolism Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18025.7, "minimum": 7462.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18025.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16112.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16820.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15153.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14216.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7462.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15057.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 12853.84, "90th_percentile": 18943.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14691.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7033.52, "90th_percentile": 7248.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7033.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3835.83, "90th_percentile": 3835.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3835.83, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10992.25, "90th_percentile": 16584.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13585.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6411.52, "90th_percentile": 6972.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6411.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4491.01, "90th_percentile": 4491.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4491.01, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4963.75, "90th_percentile": 4963.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4963.75, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 67690.82, "90th_percentile": 67690.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67690.82, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 16432.1, "90th_percentile": 16432.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16432.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8465.41, "90th_percentile": 8465.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8465.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6698.72, "90th_percentile": 7036.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6922.34, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15153.77, "90th_percentile": 15153.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15153.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7031.8, "90th_percentile": 7031.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7031.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5574.43, "90th_percentile": 5574.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5574.43, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8779.06, "90th_percentile": 8779.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8779.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8027.55, "90th_percentile": 8027.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8027.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5333.43, "90th_percentile": 7509.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7083.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15034.04, "90th_percentile": 15034.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15034.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "175", "type": "MS-DRG" } ], "description": "Pulmonary Embolism With Mcc Or Acute Cor Pulmonale", "standard_charges": [ { "billing_class": "facility", "maximum": 31184.79, "minimum": 11877.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31184.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27874.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29099.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26216.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24594.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11877.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26050.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9985.17, "90th_percentile": 11522.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 10547.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33574.03, "90th_percentile": 33574.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33574.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20372.3, "90th_percentile": 29382.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26975.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13106.09, "90th_percentile": 13106.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13106.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9343.1, "90th_percentile": 11546.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9988.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 28221.17, "90th_percentile": 28221.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28221.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7303.44, "90th_percentile": 7303.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7303.44, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7662.66, "90th_percentile": 7662.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7662.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 28011.78, "90th_percentile": 28011.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28011.78, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8465.41, "90th_percentile": 8465.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8465.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9366.13, "90th_percentile": 11546.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 11507.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 202555.26, "90th_percentile": 202555.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 202555.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10017.16, "90th_percentile": 10017.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10017.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11515.63, "90th_percentile": 11515.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11515.63, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13605.79, "90th_percentile": 13605.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13605.79, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24594.43, "90th_percentile": 26009.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24594.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2401.11, "90th_percentile": 2401.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2401.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9701.6, "90th_percentile": 11681.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 10512.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24594.43, "90th_percentile": 26009.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24594.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "173", "type": "MS-DRG" } ], "description": "Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism", "standard_charges": [ { "billing_class": "facility", "maximum": 67906.76, "minimum": 24324.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67906.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 60699.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 63365.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57087.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53555.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24324.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56725.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "168", "type": "MS-DRG" } ], "description": "Other Respiratory System O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29960.95, "minimum": 11821.81, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29960.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26780.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27957.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25187.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23629.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11821.81 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25027.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29021.32, "90th_percentile": 29021.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29021.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 828.95, "90th_percentile": 828.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 828.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11122.03, "90th_percentile": 11122.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11122.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "167", "type": "MS-DRG" } ], "description": "Other Respiratory System O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 40435.55, "minimum": 15215.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40435.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36143.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37731.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33993.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31890.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15215.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33777.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 52123.86, "90th_percentile": 52123.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52123.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14699.26, "90th_percentile": 14699.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14699.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35889.86, "90th_percentile": 35889.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35889.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14350.47, "90th_percentile": 14350.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14350.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10683.66, "90th_percentile": 10683.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10683.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14678.99, "90th_percentile": 14678.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14678.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35470.48, "90th_percentile": 35470.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35470.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33726.46, "90th_percentile": 33726.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33726.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "166", "type": "MS-DRG" } ], "description": "Other Respiratory System O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 85226.48, "minimum": 30236.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85226.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 76180.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 79527.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71647.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67215.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30236.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71193.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 84623.83, "90th_percentile": 84623.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84623.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28256.41, "90th_percentile": 28830.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28256.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22351.96, "90th_percentile": 22351.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22351.96, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 77938.52, "90th_percentile": 77938.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77938.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27149.96, "90th_percentile": 29650.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27791.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 46899.11, "90th_percentile": 46899.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46899.11, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12397.65, "90th_percentile": 12397.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12397.65, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27944.65, "90th_percentile": 27944.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27944.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 75058.48, "90th_percentile": 75058.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75058.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 29349.67, "90th_percentile": 29349.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29349.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29493.28, "90th_percentile": 29493.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29493.28, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 395608.79, "90th_percentile": 395608.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 395608.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29525.52, "90th_percentile": 29914.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29525.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "165", "type": "MS-DRG" } ], "description": "Major Chest Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41249.97, "minimum": 16075.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41249.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36871.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38491.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34677.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32532.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16075.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34457.92 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 42907.39, "90th_percentile": 42907.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42907.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14247.51, "90th_percentile": 14247.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14247.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38868.13, "90th_percentile": 39914.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39914.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 34085.55, "90th_percentile": 34085.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34085.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 9740.42, "90th_percentile": 9740.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9740.42, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10683.66, "90th_percentile": 10683.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10683.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 71207.83, "90th_percentile": 71207.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71207.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 44055.65, "90th_percentile": 44055.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44055.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 105415.35, "90th_percentile": 105415.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 105415.35, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13313.68, "90th_percentile": 13313.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13313.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34405.71, "90th_percentile": 35332.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34405.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "164", "type": "MS-DRG" } ], "description": "Major Chest Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 55699.3, "minimum": 20811.51, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55699.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 49787.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 51974.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46825.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43928.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20811.51 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46528.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 117229.7, "90th_percentile": 117229.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 117229.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18073.9, "90th_percentile": 21476.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18073.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 59013.64, "90th_percentile": 59013.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59013.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22442.62, "90th_percentile": 22442.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22442.62, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49438.91, "90th_percentile": 233711.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49791.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18305.76, "90th_percentile": 20409.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19866.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 49049.59, "90th_percentile": 49049.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49049.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 20232.38, "90th_percentile": 20232.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20232.38, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 116330.87, "90th_percentile": 116330.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 116330.87, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 18069.03, "90th_percentile": 18069.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18069.03, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17712.75, "90th_percentile": 19920.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17712.75, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 49518.36, "90th_percentile": 49518.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49518.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43931.72, "90th_percentile": 59287.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46458.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 12902.04, "90th_percentile": 12902.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12902.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18270.15, "90th_percentile": 18270.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18270.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 45901.96, "90th_percentile": 61577.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46215.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "163", "type": "MS-DRG" } ], "description": "Major Chest Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 101999.57, "minimum": 36015.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101999.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 91173.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 95178.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85748.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80443.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36015.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 85204.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 104788.97, "90th_percentile": 104788.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 104788.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19862.08, "90th_percentile": 35648.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 33708.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8465.41, "90th_percentile": 8465.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8465.41, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90533.91, "90th_percentile": 93454.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 90533.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32194.42, "90th_percentile": 37183.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 35634.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 90664.19, "90th_percentile": 90664.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90664.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 164121.37, "90th_percentile": 164121.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 164121.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7662.66, "90th_percentile": 20314.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7662.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7166.28, "90th_percentile": 7166.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7166.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 35428.64, "90th_percentile": 35428.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35428.64, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21326.87, "90th_percentile": 35755.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 34227.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 90427.89, "90th_percentile": 90427.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90427.89, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 49650.93, "90th_percentile": 49650.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49650.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 35648.67, "90th_percentile": 35753.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35648.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4341.73, "90th_percentile": 22351.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4341.73, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 80448.98, "90th_percentile": 80842.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80448.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8027.55, "90th_percentile": 8027.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8027.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21538.92, "90th_percentile": 36102.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34524.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 80448.98, "90th_percentile": 156585.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 81132.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "159", "type": "MS-DRG" } ], "description": "Dental And Oral Diseases Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14597.61, "minimum": 6712.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14597.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13048.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13621.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12271.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11512.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6712.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12194.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19604.33, "90th_percentile": 19604.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19604.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6349.89, "90th_percentile": 6349.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6349.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5817.12, "90th_percentile": 5817.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5817.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12194.03, "90th_percentile": 12194.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12194.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "158", "type": "MS-DRG" } ], "description": "Dental And Oral Diseases With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 20814.21, "minimum": 8275.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20814.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18604.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19422.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17498.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16415.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8275.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17387.02 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7308.84, "90th_percentile": 7980.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7308.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16034.16, "90th_percentile": 18475.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16822.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8113.52, "90th_percentile": 8113.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8113.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3917.26, "90th_percentile": 3917.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3917.26, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7992.55, "90th_percentile": 7992.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7992.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6337.76, "90th_percentile": 6337.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6337.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23439.6, "90th_percentile": 23439.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23439.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6009.95, "90th_percentile": 6009.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6009.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6133.03, "90th_percentile": 6133.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6133.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "157", "type": "MS-DRG" } ], "description": "Dental And Oral Diseases With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36237.3, "minimum": 14542.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36237.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32391.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33813.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30463.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28579.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14542.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30270.61 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13144.03, "90th_percentile": 13144.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13144.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32975.78, "90th_percentile": 32975.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32975.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37342.86, "90th_percentile": 37342.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37342.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13163.54, "90th_percentile": 13163.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13163.54, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13229.94, "90th_percentile": 13229.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13229.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13241.74, "90th_percentile": 13241.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13241.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 14697.95, "90th_percentile": 14697.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14697.95, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12223.05, "90th_percentile": 12223.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12223.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30224.98, "90th_percentile": 30224.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30224.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "156", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14880.88, "minimum": 6577.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14880.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13301.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13885.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12510.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11736.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6577.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12430.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13301.42, "90th_percentile": 13301.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13301.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5951.49, "90th_percentile": 5951.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5951.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5736.77, "90th_percentile": 5736.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5736.77, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10818.94, "90th_percentile": 10818.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10818.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "155", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth And Throat Diagnoses With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 20661.5, "minimum": 8327.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20661.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18468.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19279.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17369.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16295.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8327.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17259.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9454.49, "90th_percentile": 9454.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9454.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7288.62, "90th_percentile": 7927.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7288.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18337.77, "90th_percentile": 18337.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18337.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5190.41, "90th_percentile": 5190.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5190.41, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6337.76, "90th_percentile": 6337.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6337.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5705.64, "90th_percentile": 5705.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5705.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18316.3, "90th_percentile": 18316.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18316.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7498.09, "90th_percentile": 7498.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7498.09, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 655.66, "90th_percentile": 655.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 655.66, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8163.75, "90th_percentile": 8163.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8163.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "154", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth And Throat Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35989.43, "minimum": 13352.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35989.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32169.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33582.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30255.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28383.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13352.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30063.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32171.47, "90th_percentile": 32171.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32171.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13155.66, "90th_percentile": 13155.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13155.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 89737.58, "90th_percentile": 89737.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 89737.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13382.05, "90th_percentile": 13382.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13382.05, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12349.49, "90th_percentile": 12349.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12349.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49162.22, "90th_percentile": 49162.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49162.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "153", "type": "MS-DRG" } ], "description": "Otitis Media And Uri Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15750.63, "minimum": 6943.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15750.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14078.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14697.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13241.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12422.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6943.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13157.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 10850.55, "90th_percentile": 10850.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10850.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5548.06, "90th_percentile": 5548.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5548.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9732.8, "90th_percentile": 13366.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10028.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3339.8, "90th_percentile": 3339.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3339.8, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11558.71, "90th_percentile": 11558.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11558.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5181.09, "90th_percentile": 5181.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5181.09, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4928.88, "90th_percentile": 4928.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4928.88, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 3834.11, "90th_percentile": 3834.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3834.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12422.01, "90th_percentile": 13625.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12422.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "152", "type": "MS-DRG" } ], "description": "Otitis Media And Uri With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25112.05, "minimum": 10391.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25112.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22446.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23432.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21111.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19805.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10391.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20977.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8759.32, "90th_percentile": 8759.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8759.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24651.23, "90th_percentile": 24651.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24651.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9453.19, "90th_percentile": 9453.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9453.19, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8270.03, "90th_percentile": 8270.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8270.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "151", "type": "MS-DRG" } ], "description": "Epistaxis Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16775.3, "minimum": 6910.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16775.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14994.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15653.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14102.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13230.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6910.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14013.15 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6648.35, "90th_percentile": 6648.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6648.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6597.09, "90th_percentile": 6638.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6597.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 10926.55, "90th_percentile": 10926.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10926.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6146.26, "90th_percentile": 6712.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6599.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5382.48, "90th_percentile": 5382.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5382.48, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6661.08, "90th_percentile": 6661.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6661.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "150", "type": "MS-DRG" } ], "description": "Epistaxis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 30587.26, "minimum": 11550.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30587.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27340.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28541.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25713.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24123.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11550.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25550.88 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11299.76, "90th_percentile": 11299.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11299.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10327.66, "90th_percentile": 10327.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10327.66, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24124.92, "90th_percentile": 24124.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24124.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "149", "type": "MS-DRG" } ], "description": "Dysequilibrium", "standard_charges": [ { "billing_class": "facility", "maximum": 16542.92, "minimum": 7047.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16542.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14787.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15436.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13907.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13046.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7047.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13819.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16527.23, "90th_percentile": 16527.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16527.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6274.93, "90th_percentile": 6274.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6274.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14293.16, "90th_percentile": 14293.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14293.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4875.52, "90th_percentile": 4875.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4875.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4714.69, "90th_percentile": 6578.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6517.89, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 529.85, "90th_percentile": 529.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 529.85, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 529.85, "90th_percentile": 529.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 529.85, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13797.36, "90th_percentile": 13797.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13797.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6582.3, "90th_percentile": 6582.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6582.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "148", "type": "MS-DRG" } ], "description": "Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17720.29, "minimum": 7400.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17720.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15839.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16535.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14897.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13975.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7400.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14802.54 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "147", "type": "MS-DRG" } ], "description": "Ear, Nose, Mouth And Throat Malignancy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 27546.46, "minimum": 11084.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27546.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24622.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25704.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23157.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21724.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11084.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23010.77 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10039.34, "90th_percentile": 10039.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10039.34, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "146", "type": "MS-DRG" } ], "description": "Ear, Nose, Mouth And Throat Malignancy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 50766.3, "minimum": 17653.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50766.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45377.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47371.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42678.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40037.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17653.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42407.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17233.67, "90th_percentile": 17233.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17233.67, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41276.7, "90th_percentile": 41276.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41276.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17264.13, "90th_percentile": 17264.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17264.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9957.28, "90th_percentile": 9957.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9957.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17722.98, "90th_percentile": 17722.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17722.98, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 45007.95, "90th_percentile": 45007.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45007.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 17953.46, "90th_percentile": 17953.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17953.46, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10431.43, "90th_percentile": 10431.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10431.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18422.0, "90th_percentile": 18422.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18422.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "145", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 26218.6, "minimum": 10547.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26218.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23435.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24465.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20677.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10547.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21901.55 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 26220.81, "90th_percentile": 26220.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26220.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23078.83, "90th_percentile": 23078.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23078.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9407.64, "90th_percentile": 9407.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9407.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 40321.57, "90th_percentile": 40321.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40321.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "144", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 38875.31, "minimum": 14667.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38875.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34749.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36275.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32681.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30659.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14667.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32474.26 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14125.25, "90th_percentile": 14125.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14125.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31377.08, "90th_percentile": 36630.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31377.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9369.99, "90th_percentile": 9369.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9369.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34563.52, "90th_percentile": 34563.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34563.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2466.0, "90th_percentile": 2466.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2466.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30960.25, "90th_percentile": 30960.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30960.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "143", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 73069.92, "minimum": 30305.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73069.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 65314.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 68183.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61428.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57627.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30305.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 61038.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25782.22, "90th_percentile": 25782.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25782.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5736.77, "90th_percentile": 5736.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5736.77, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6844.93, "90th_percentile": 6844.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6844.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25795.72, "90th_percentile": 25795.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25795.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24546.63, "90th_percentile": 24546.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24546.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "142", "type": "MS-DRG" } ], "description": "Major Head And Neck Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34796.57, "minimum": 13607.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34796.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31103.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32469.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29252.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27442.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13607.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29067.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30848.92, "90th_percentile": 30848.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30848.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "141", "type": "MS-DRG" } ], "description": "Major Head And Neck Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 47544.03, "minimum": 18148.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47544.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42497.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44364.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39969.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37496.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18148.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39715.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 49193.12, "90th_percentile": 49193.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49193.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40139.97, "90th_percentile": 40139.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40139.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17109.84, "90th_percentile": 17109.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17109.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10032.07, "90th_percentile": 10032.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10032.07, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 10260.94, "90th_percentile": 10260.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10260.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17082.11, "90th_percentile": 17082.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17082.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37716.79, "90th_percentile": 37716.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37716.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15328.32, "90th_percentile": 15328.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15328.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39657.01, "90th_percentile": 39657.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39657.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "140", "type": "MS-DRG" } ], "description": "Major Head And Neck Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 93592.0, "minimum": 34334.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93592.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 83658.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 87333.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78680.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73812.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34334.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 78181.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 18829.16, "90th_percentile": 18829.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18829.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "570", "type": "MS-DRG" } ], "description": "Skin Debridement With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 66623.16, "minimum": 24050.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66623.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 59551.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 62167.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56008.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52543.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24050.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55653.26 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23761.85, "90th_percentile": 23761.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23761.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23364.75, "90th_percentile": 23364.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23364.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 56246.4, "90th_percentile": 56246.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56246.4, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7478.35, "90th_percentile": 7478.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7478.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23796.81, "90th_percentile": 23796.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23796.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "571", "type": "MS-DRG" } ], "description": "Skin Debridement With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 37065.0, "minimum": 14330.94, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37065.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33130.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34586.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31159.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29231.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14330.94 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30962.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 31601.76, "90th_percentile": 31601.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31601.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8649.64, "90th_percentile": 13944.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8649.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32886.6, "90th_percentile": 32886.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32886.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11684.66, "90th_percentile": 11684.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11684.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 20164.52, "90th_percentile": 20164.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20164.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5459.84, "90th_percentile": 5459.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5459.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5618.73, "90th_percentile": 5618.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5618.73, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12056.03, "90th_percentile": 12056.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12056.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32848.09, "90th_percentile": 32848.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32848.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 14497.12, "90th_percentile": 14497.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14497.12, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12357.8, "90th_percentile": 12357.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12357.8, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13302.4, "90th_percentile": 14208.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13302.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "572", "type": "MS-DRG" } ], "description": "Skin Debridement Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25282.45, "minimum": 10112.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25282.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22598.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23591.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21254.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19939.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10112.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21119.55 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17419.63, "90th_percentile": 17419.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17419.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23821.32, "90th_percentile": 23821.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23821.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8448.41, "90th_percentile": 8448.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8448.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "573", "type": "MS-DRG" } ], "description": "Skin Graft For Skin Ulcer Or Cellulitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 136278.27, "minimum": 52087.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 136278.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 121813.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 127164.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 114565.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 107478.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52087.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 113839.25 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 27593.11, "90th_percentile": 27593.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27593.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "574", "type": "MS-DRG" } ], "description": "Skin Graft For Skin Ulcer Or Cellulitis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 76677.28, "minimum": 28168.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76677.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 68538.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 71549.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64460.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60472.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28168.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64051.91 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14603.76, "90th_percentile": 14603.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14603.76, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 220947.1, "90th_percentile": 220947.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 220947.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "575", "type": "MS-DRG" } ], "description": "Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 44184.54, "minimum": 15165.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44184.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39494.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41229.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37144.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34846.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15165.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36909.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "576", "type": "MS-DRG" } ], "description": "Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 119394.53, "minimum": 39272.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 119394.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 106721.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 111410.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 100372.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 94162.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39272.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 99735.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39443.28, "90th_percentile": 39443.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39443.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41697.08, "90th_percentile": 41697.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41697.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "577", "type": "MS-DRG" } ], "description": "Skin Graft Except For Skin Ulcer Or Cellulitis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 58926.0, "minimum": 21795.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58926.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52671.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 54985.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49537.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46473.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21795.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49223.49 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 1896.29, "90th_percentile": 1896.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1896.29, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19526.62, "90th_percentile": 19526.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19526.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "578", "type": "MS-DRG" } ], "description": "Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 37408.03, "minimum": 13685.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37408.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33437.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34906.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31448.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29502.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13685.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31248.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10624.41, "90th_percentile": 10624.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10624.41, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "579", "type": "MS-DRG" } ], "description": "Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 72127.14, "minimum": 26360.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72127.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 64471.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 67303.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60635.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56884.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26360.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60250.98 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24934.11, "90th_percentile": 25624.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24934.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 64021.13, "90th_percentile": 64021.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64021.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23160.91, "90th_percentile": 23160.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23160.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 22769.01, "90th_percentile": 22769.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22769.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11702.11, "90th_percentile": 11702.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11702.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 25641.59, "90th_percentile": 25641.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25641.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 25526.19, "90th_percentile": 25526.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25526.19, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16564.53, "90th_percentile": 16564.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16564.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24879.83, "90th_percentile": 25412.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24879.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 105572.65, "90th_percentile": 105572.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 105572.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "580", "type": "MS-DRG" } ], "description": "Other Skin, Subcutaneous Tissue And Breast Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 39236.05, "minimum": 14629.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39236.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35071.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36612.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32984.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30944.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14629.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32775.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 46717.58, "90th_percentile": 46717.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46717.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12179.29, "90th_percentile": 12365.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12240.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33342.94, "90th_percentile": 35600.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33805.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14245.91, "90th_percentile": 14245.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14245.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5373.21, "90th_percentile": 10858.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6893.33, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13461.01, "90th_percentile": 13461.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13461.01, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12269.31, "90th_percentile": 14251.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14251.81, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36717.52, "90th_percentile": 36717.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36717.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16564.53, "90th_percentile": 16564.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16564.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11375.46, "90th_percentile": 11375.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11375.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14393.77, "90th_percentile": 14393.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14393.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29194.17, "90th_percentile": 29194.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29194.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "581", "type": "MS-DRG" } ], "description": "Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31848.72, "minimum": 12417.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31848.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28468.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29718.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26774.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25118.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12417.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26604.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28470.25, "90th_percentile": 28470.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28470.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 15850.54, "90th_percentile": 15850.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15850.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6236.83, "90th_percentile": 6236.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6236.83, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5373.21, "90th_percentile": 5373.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5373.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11084.62, "90th_percentile": 11084.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11084.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24832.48, "90th_percentile": 24832.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24832.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10811.75, "90th_percentile": 10811.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10811.75, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16564.53, "90th_percentile": 16564.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16564.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11874.32, "90th_percentile": 11874.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11874.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "582", "type": "MS-DRG" } ], "description": "Mastectomy For Malignancy With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38753.59, "minimum": 16172.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38753.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34640.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36161.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32579.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30563.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16172.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32372.59 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "583", "type": "MS-DRG" } ], "description": "Mastectomy For Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36350.17, "minimum": 14601.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36350.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32491.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33919.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30558.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28668.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14601.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30364.9 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "584", "type": "MS-DRG" } ], "description": "Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 45308.8, "minimum": 17834.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45308.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40499.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 42278.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38090.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35733.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17834.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37848.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40144.65, "90th_percentile": 40144.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40144.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15419.65, "90th_percentile": 15419.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15419.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "585", "type": "MS-DRG" } ], "description": "Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43930.04, "minimum": 16191.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43930.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39267.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40992.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36930.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34646.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16191.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36696.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14819.84, "90th_percentile": 14819.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14819.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "592", "type": "MS-DRG" } ], "description": "Skin Ulcers With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 45505.76, "minimum": 16239.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45505.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40675.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 42462.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38255.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35888.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16239.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38012.97 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16388.52, "90th_percentile": 16388.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16388.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39689.84, "90th_percentile": 39689.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39689.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14133.61, "90th_percentile": 14133.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14133.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14450.82, "90th_percentile": 14450.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14450.82, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "593", "type": "MS-DRG" } ], "description": "Skin Ulcers With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 27057.36, "minimum": 10423.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27057.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24185.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25247.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22746.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21339.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10423.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22602.21 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10097.4, "90th_percentile": 10097.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10097.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8828.69, "90th_percentile": 8828.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8828.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "594", "type": "MS-DRG" } ], "description": "Skin Ulcers Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18780.37, "minimum": 7942.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18780.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16787.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17524.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15788.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14811.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7942.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15688.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "595", "type": "MS-DRG" } ], "description": "Major Skin Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 46807.07, "minimum": 17679.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46807.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41838.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43676.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39349.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36915.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17679.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39100.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 35492.68, "90th_percentile": 35492.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35492.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "596", "type": "MS-DRG" } ], "description": "Major Skin Disorders Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 23923.61, "minimum": 9617.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23923.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21384.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22323.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20112.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18867.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9617.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19984.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22572.29, "90th_percentile": 22572.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22572.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8506.0, "90th_percentile": 8506.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8506.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 21863.85, "90th_percentile": 21863.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21863.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5183.54, "90th_percentile": 5183.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5183.54, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9065.14, "90th_percentile": 9065.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9065.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14031.85, "90th_percentile": 14031.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14031.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19954.94, "90th_percentile": 19954.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19954.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "597", "type": "MS-DRG" } ], "description": "Malignant Breast Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38873.1, "minimum": 14156.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38873.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34747.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36273.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32679.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30657.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14156.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32472.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7994.85, "90th_percentile": 7994.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7994.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8066.88, "90th_percentile": 8066.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8066.88, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14257.74, "90th_percentile": 14257.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14257.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36373.14, "90th_percentile": 36373.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36373.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "598", "type": "MS-DRG" } ], "description": "Malignant Breast Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23877.14, "minimum": 9996.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23877.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21342.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22280.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20072.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18831.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9996.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19945.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4895.4, "90th_percentile": 4895.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4895.4, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7659.35, "90th_percentile": 7659.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7659.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21318.25, "90th_percentile": 21318.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21318.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "599", "type": "MS-DRG" } ], "description": "Malignant Breast Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18919.79, "minimum": 7185.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18919.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16911.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17654.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15905.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14921.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7185.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15804.54 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 23191.92, "90th_percentile": 23191.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23191.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "600", "type": "MS-DRG" } ], "description": "Non-Malignant Breast Disorders With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21183.79, "minimum": 9299.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21183.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18935.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19767.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17808.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16706.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9299.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17695.76 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "601", "type": "MS-DRG" } ], "description": "Non-Malignant Breast Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 13267.53, "minimum": 5908.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13267.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11859.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12380.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11153.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10463.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5908.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11082.96 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10463.67, "90th_percentile": 10463.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10463.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "602", "type": "MS-DRG" } ], "description": "Cellulitis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32519.29, "minimum": 12248.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32519.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29067.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30344.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27338.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25646.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12248.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27164.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10912.05, "90th_percentile": 21826.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10935.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28679.0, "90th_percentile": 29063.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28679.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7546.34, "90th_percentile": 7546.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7546.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11831.66, "90th_percentile": 12000.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11960.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 19714.9, "90th_percentile": 19714.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19714.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7138.43, "90th_percentile": 8209.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7138.43, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 6108.76, "90th_percentile": 6108.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6108.76, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7146.59, "90th_percentile": 12034.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9870.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13315.14, "90th_percentile": 13315.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13315.14, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7886.26, "90th_percentile": 7886.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7886.26, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12426.08, "90th_percentile": 12426.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12426.08, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8700.9, "90th_percentile": 12069.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10472.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "603", "type": "MS-DRG" } ], "description": "Cellulitis Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19495.2, "minimum": 7973.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19495.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17425.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18191.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16389.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15375.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7973.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16285.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20362.51, "90th_percentile": 20362.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20362.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5468.07, "90th_percentile": 7010.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6887.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11737.0, "90th_percentile": 11737.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11737.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7615.49, "90th_percentile": 7615.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7615.49, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12556.18, "90th_percentile": 18366.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 15367.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5376.54, "90th_percentile": 5376.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5376.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5679.3, "90th_percentile": 7216.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6748.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 6330.63, "90th_percentile": 11793.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7458.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5424.98, "90th_percentile": 5424.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5424.98, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9580.74, "90th_percentile": 9580.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9580.74, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4064.85, "90th_percentile": 7138.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5373.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2897.83, "90th_percentile": 2897.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2897.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7664.14, "90th_percentile": 7664.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7664.14, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4490.7, "90th_percentile": 5709.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4581.36, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5381.87, "90th_percentile": 7584.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 6898.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15888.23, "90th_percentile": 17086.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15951.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5618.73, "90th_percentile": 7615.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5709.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7799.12, "90th_percentile": 7799.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7799.12, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16603.55, "90th_percentile": 16603.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16603.55, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 158.31, "90th_percentile": 158.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 158.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5629.07, "90th_percentile": 7478.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7478.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5555.84, "90th_percentile": 7620.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 7158.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15373.48, "90th_percentile": 16257.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15373.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "604", "type": "MS-DRG" } ], "description": "Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32880.03, "minimum": 12642.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32880.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29390.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30681.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27641.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25931.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12642.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27466.14 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12087.49, "90th_percentile": 12087.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12087.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30979.82, "90th_percentile": 30979.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30979.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12184.15, "90th_percentile": 12184.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12184.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 19343.86, "90th_percentile": 19343.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19343.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 12310.42, "90th_percentile": 12310.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12310.42, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12142.51, "90th_percentile": 12142.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12142.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8722.57, "90th_percentile": 8722.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8722.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9985.03, "90th_percentile": 9985.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9985.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24898.08, "90th_percentile": 24898.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24898.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "605", "type": "MS-DRG" } ], "description": "Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20442.4, "minimum": 8324.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20442.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18272.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19075.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17185.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16122.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8324.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17076.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20638.97, "90th_percentile": 20638.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20638.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6709.13, "90th_percentile": 7900.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 7221.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2594.79, "90th_percentile": 2594.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2594.79, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16399.15, "90th_percentile": 16399.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16399.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8761.16, "90th_percentile": 8761.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8761.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6370.63, "90th_percentile": 7873.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7843.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16257.74, "90th_percentile": 16257.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16257.74, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3585.03, "90th_percentile": 4969.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4969.67, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7735.21, "90th_percentile": 8085.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7853.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17162.02, "90th_percentile": 17162.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17162.02, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12502.27, "90th_percentile": 12502.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12502.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6448.64, "90th_percentile": 23035.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7918.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "606", "type": "MS-DRG" } ], "description": "Minor Skin Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35633.12, "minimum": 12961.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35633.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31851.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33250.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29955.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28102.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12961.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29765.92 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13024.99, "90th_percentile": 13024.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13024.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15968.9, "90th_percentile": 15968.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15968.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12591.42, "90th_percentile": 12591.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12591.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1343.69, "90th_percentile": 1343.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1343.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29722.92, "90th_percentile": 29722.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29722.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "607", "type": "MS-DRG" } ], "description": "Minor Skin Disorders Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19127.82, "minimum": 8249.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19127.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17097.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17848.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16080.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15085.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8249.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15978.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5751.34, "90th_percentile": 5751.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5751.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21192.54, "90th_percentile": 21192.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21192.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14872.4, "90th_percentile": 18673.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15840.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7413.66, "90th_percentile": 7413.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7413.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5459.84, "90th_percentile": 5541.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5459.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7111.64, "90th_percentile": 7111.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7111.64, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7417.18, "90th_percentile": 7417.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7417.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16349.7, "90th_percentile": 16349.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16349.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4955.32, "90th_percentile": 4955.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4955.32, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15951.4, "90th_percentile": 15951.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15951.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2428.17, "90th_percentile": 2428.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2428.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "614", "type": "MS-DRG" } ], "description": "Adrenal And Pituitary Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 50432.12, "minimum": 18231.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50432.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45079.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47059.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42397.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39774.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18231.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42128.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17572.63, "90th_percentile": 17572.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17572.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44764.12, "90th_percentile": 47521.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44864.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 15356.63, "90th_percentile": 15356.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15356.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16127.65, "90th_percentile": 18056.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17103.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6595.2, "90th_percentile": 6595.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6595.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 16048.37, "90th_percentile": 16048.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16048.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17147.17, "90th_percentile": 17240.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17147.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46376.14, "90th_percentile": 175945.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46376.14, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12164.46, "90th_percentile": 12255.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12164.46, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 43049.61, "90th_percentile": 43049.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43049.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1568.0, "90th_percentile": 1568.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1568.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "615", "type": "MS-DRG" } ], "description": "Adrenal And Pituitary Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31711.51, "minimum": 12077.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31711.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28345.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29590.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26659.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25009.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12077.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26490.02 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11690.56, "90th_percentile": 11690.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11690.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28146.99, "90th_percentile": 28347.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28146.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10040.27, "90th_percentile": 10040.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10040.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 15494.98, "90th_percentile": 15494.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15494.98, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11010.93, "90th_percentile": 11010.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11010.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 43893.31, "90th_percentile": 43893.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43893.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26450.31, "90th_percentile": 26450.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26450.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11880.33, "90th_percentile": 11880.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11880.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27608.22, "90th_percentile": 27608.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27608.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "616", "type": "MS-DRG" } ], "description": "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 85534.1, "minimum": 28293.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85534.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 76455.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 79814.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71906.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67457.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28293.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71450.41 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15459.66, "90th_percentile": 27289.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27289.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28307.29, "90th_percentile": 28307.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28307.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 17094.39, "90th_percentile": 17094.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17094.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 114726.98, "90th_percentile": 114726.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 114726.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 30737.51, "90th_percentile": 30737.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30737.51, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 16176.66, "90th_percentile": 25889.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16176.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30028.92, "90th_percentile": 30139.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30053.21, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 75827.44, "90th_percentile": 75827.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75827.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 48471.03, "90th_percentile": 48471.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48471.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23550.1, "90th_percentile": 23550.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23550.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 190739.78, "90th_percentile": 190739.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 190739.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22931.49, "90th_percentile": 30288.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26433.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "617", "type": "MS-DRG" } ], "description": "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 42761.52, "minimum": 15735.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42761.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38222.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39901.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35948.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33724.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15735.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35720.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 45162.74, "90th_percentile": 45162.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45162.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14091.94, "90th_percentile": 15595.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14091.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9709.47, "90th_percentile": 9709.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9709.47, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35115.21, "90th_percentile": 38999.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37940.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13321.35, "90th_percentile": 15492.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13799.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7877.47, "90th_percentile": 9287.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7877.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8706.67, "90th_percentile": 10447.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8706.67, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 33979.65, "90th_percentile": 33979.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33979.65, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9618.8, "90th_percentile": 9618.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9618.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11176.21, "90th_percentile": 15019.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 13306.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38067.93, "90th_percentile": 38067.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38067.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13685.04, "90th_percentile": 13685.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13685.04, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16086.0, "90th_percentile": 16086.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16086.0, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15843.59, "90th_percentile": 15843.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15843.59, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13555.24, "90th_percentile": 15618.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 13903.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33714.15, "90th_percentile": 35653.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33714.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "618", "type": "MS-DRG" } ], "description": "Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27553.1, "minimum": 12224.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27553.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24628.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25710.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23163.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21730.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12224.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23016.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "619", "type": "MS-DRG" } ], "description": "O.R. Procedures For Obesity With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 60337.96, "minimum": 23633.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60337.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53933.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 56302.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50724.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47586.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23633.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50402.96 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 22223.19, "90th_percentile": 22223.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22223.19, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12164.46, "90th_percentile": 12164.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12164.46, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 70217.55, "90th_percentile": 70217.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 70217.55, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 27376.16, "90th_percentile": 27376.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27376.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20079.68, "90th_percentile": 20079.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20079.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "620", "type": "MS-DRG" } ], "description": "O.R. Procedures For Obesity With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 35340.99, "minimum": 13638.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35340.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31589.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32977.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29710.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27872.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13638.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29521.89 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 74344.39, "90th_percentile": 74344.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74344.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11662.58, "90th_percentile": 12931.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11961.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11239.29, "90th_percentile": 11239.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11239.29, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29820.38, "90th_percentile": 33300.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29820.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12933.0, "90th_percentile": 12981.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12933.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10173.49, "90th_percentile": 10255.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10173.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 854.19, "90th_percentile": 854.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 854.19, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10819.55, "90th_percentile": 10819.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10819.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31331.54, "90th_percentile": 31331.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31331.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27874.04, "90th_percentile": 29477.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27874.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10657.94, "90th_percentile": 10657.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10657.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11288.23, "90th_percentile": 11288.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11288.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27838.3, "90th_percentile": 29477.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27874.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "621", "type": "MS-DRG" } ], "description": "O.R. Procedures For Obesity Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32348.88, "minimum": 12924.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32348.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28915.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30185.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27194.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25512.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12924.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27022.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 670.5, "90th_percentile": 76203.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 32136.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11472.4, "90th_percentile": 12243.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11472.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24405.78, "90th_percentile": 30481.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 28677.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10754.83, "90th_percentile": 10841.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10754.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12063.55, "90th_percentile": 12063.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12063.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8377.9, "90th_percentile": 10851.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9204.59, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10173.49, "90th_percentile": 10173.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 10173.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 31772.22, "90th_percentile": 142886.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77235.92, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11329.95, "90th_percentile": 11329.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11329.95, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11945.15, "90th_percentile": 11945.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11945.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27196.79, "90th_percentile": 28679.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27196.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10229.85, "90th_percentile": 11239.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11239.29, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25514.26, "90th_percentile": 27842.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 25514.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9700.72, "90th_percentile": 10657.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10657.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11833.04, "90th_percentile": 12016.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11833.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25514.26, "90th_percentile": 27379.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 25514.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "622", "type": "MS-DRG" } ], "description": "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 82858.46, "minimum": 28850.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82858.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 74063.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 77317.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69657.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65347.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28850.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 69215.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19726.31, "90th_percentile": 19726.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19726.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 9374.9, "90th_percentile": 9374.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9374.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17432.63, "90th_percentile": 17432.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17432.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 73945.83, "90th_percentile": 73945.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73945.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "623", "type": "MS-DRG" } ], "description": "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 42358.73, "minimum": 15141.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42358.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37862.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39526.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35609.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33406.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15141.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35384.12 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13395.33, "90th_percentile": 14263.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13713.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16021.15, "90th_percentile": 37839.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37839.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6858.29, "90th_percentile": 6858.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6858.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11565.57, "90th_percentile": 15306.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14394.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 18033.72, "90th_percentile": 18033.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18033.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15342.53, "90th_percentile": 15342.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15342.53, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15940.12, "90th_percentile": 15940.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15940.12, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13676.2, "90th_percentile": 13676.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13676.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "624", "type": "MS-DRG" } ], "description": "Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22199.61, "minimum": 10932.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22199.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19843.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20715.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18662.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17508.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10932.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18544.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "625", "type": "MS-DRG" } ], "description": "Thyroid, Parathyroid And Thyroglossal Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 63447.36, "minimum": 24664.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63447.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 56713.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 59204.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53338.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50038.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24664.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53000.38 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23273.94, "90th_percentile": 23273.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23273.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22188.39, "90th_percentile": 22188.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22188.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "626", "type": "MS-DRG" } ], "description": "Thyroid, Parathyroid And Thyroglossal Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 33400.11, "minimum": 12854.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33400.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29854.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31166.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28078.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26341.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12854.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27900.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10135.72, "90th_percentile": 10135.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10135.72, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "627", "type": "MS-DRG" } ], "description": "Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28035.55, "minimum": 11525.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28035.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25059.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26160.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23568.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22110.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11525.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23419.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10439.65, "90th_percentile": 10439.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10439.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "628", "type": "MS-DRG" } ], "description": "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 87335.57, "minimum": 30152.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87335.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 78065.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 81495.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73420.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68878.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30152.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72955.25 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 86822.11, "90th_percentile": 86822.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 86822.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26828.41, "90th_percentile": 26828.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26828.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28825.42, "90th_percentile": 28825.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28825.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7864.14, "90th_percentile": 7864.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7864.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29192.76, "90th_percentile": 29192.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29192.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 171964.73, "90th_percentile": 171964.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 171964.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "629", "type": "MS-DRG" } ], "description": "Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 49796.96, "minimum": 18130.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49796.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44511.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46466.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41863.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39273.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18130.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41597.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 52380.33, "90th_percentile": 52380.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52380.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16266.62, "90th_percentile": 16266.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16266.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 45432.34, "90th_percentile": 45432.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45432.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11852.88, "90th_percentile": 17834.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17334.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8403.83, "90th_percentile": 8403.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8403.83, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17842.39, "90th_percentile": 17842.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17842.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41892.34, "90th_percentile": 41892.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41892.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16625.25, "90th_percentile": 16625.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16625.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "630", "type": "MS-DRG" } ], "description": "Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31009.96, "minimum": 12544.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31009.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27718.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28936.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26069.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24456.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12544.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25903.98 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22804.61, "90th_percentile": 22804.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22804.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "637", "type": "MS-DRG" } ], "description": "Diabetes With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32229.38, "minimum": 12367.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32229.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28808.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30074.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27094.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25418.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12367.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26922.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 24149.09, "90th_percentile": 55097.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24149.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7706.65, "90th_percentile": 11856.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 10096.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 10319.09, "90th_percentile": 10319.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10319.09, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5023.22, "90th_percentile": 12649.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5023.22, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26445.91, "90th_percentile": 30366.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28179.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 12104.29, "90th_percentile": 12104.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12104.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9038.62, "90th_percentile": 11897.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10377.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 13953.12, "90th_percentile": 13953.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13953.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5792.67, "90th_percentile": 5792.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5792.67, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6402.43, "90th_percentile": 11450.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6402.43, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 9977.15, "90th_percentile": 9977.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9977.15, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 12740.2, "90th_percentile": 12740.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12740.2, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9600.53, "90th_percentile": 11934.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10682.34, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10432.72, "90th_percentile": 10432.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10432.72, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11957.53, "90th_percentile": 11957.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11957.53, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5094.27, "90th_percentile": 12649.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7073.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10649.09, "90th_percentile": 12362.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12297.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24436.41, "90th_percentile": 25164.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24436.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6793.28, "90th_percentile": 6793.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6793.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1185.64, "90th_percentile": 12124.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 10446.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26880.39, "90th_percentile": 26880.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26880.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "638", "type": "MS-DRG" } ], "description": "Diabetes With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 20298.55, "minimum": 8170.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20298.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18144.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18941.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17064.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16008.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8170.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16956.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 19472.42, "90th_percentile": 20279.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19472.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5480.27, "90th_percentile": 7476.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 6842.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 7198.37, "90th_percentile": 7198.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7198.37, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4845.58, "90th_percentile": 5023.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4845.58, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13226.45, "90th_percentile": 18687.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 18015.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6155.25, "90th_percentile": 7797.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6176.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 10479.72, "90th_percentile": 15749.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10479.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3968.36, "90th_percentile": 6920.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4590.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4304.01, "90th_percentile": 5787.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 4386.08, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19935.34, "90th_percentile": 19935.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19935.34, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7939.04, "90th_percentile": 7939.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7939.04, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5023.22, "90th_percentile": 5023.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5023.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5543.7, "90th_percentile": 7797.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5833.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15597.93, "90th_percentile": 15597.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15597.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7157.57, "90th_percentile": 7157.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7157.57, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4754.91, "90th_percentile": 5023.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 4754.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8078.84, "90th_percentile": 8078.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8078.84, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10521.41, "90th_percentile": 16929.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16008.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4763.4, "90th_percentile": 6796.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4763.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5746.07, "90th_percentile": 7577.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 6242.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13601.82, "90th_percentile": 16929.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16008.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "639", "type": "MS-DRG" } ], "description": "Diabetes Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 13867.28, "minimum": 6034.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13867.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12395.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12939.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11657.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10936.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6034.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11583.95 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13135.89, "90th_percentile": 13867.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13135.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10807.69, "90th_percentile": 11312.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11189.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4549.96, "90th_percentile": 4806.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4549.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4590.95, "90th_percentile": 4590.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4590.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4304.01, "90th_percentile": 4304.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4304.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 9406.8, "90th_percentile": 9406.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9406.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5690.99, "90th_percentile": 5690.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5690.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10777.25, "90th_percentile": 10777.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10777.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4845.58, "90th_percentile": 5113.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5023.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4737.7, "90th_percentile": 4737.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4737.7, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19717.3, "90th_percentile": 19717.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19717.3, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24649.89, "90th_percentile": 24649.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24649.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4508.97, "90th_percentile": 4508.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4508.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10655.84, "90th_percentile": 11565.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10655.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "640", "type": "MS-DRG" } ], "description": "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 29392.18, "minimum": 11582.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29392.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26272.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27426.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24709.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23180.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11582.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24552.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 28921.65, "90th_percentile": 30949.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28921.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8443.34, "90th_percentile": 10934.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 9625.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 8657.93, "90th_percentile": 8657.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8657.93, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5894.4, "90th_percentile": 5894.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5894.4, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25384.58, "90th_percentile": 26084.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26084.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 13305.83, "90th_percentile": 13305.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13305.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9251.48, "90th_percentile": 11251.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 10484.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 9170.43, "90th_percentile": 9170.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9170.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 9743.87, "90th_percentile": 9743.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9743.87, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7601.2, "90th_percentile": 10769.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7601.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10051.58, "90th_percentile": 10051.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10051.58, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8488.18, "90th_percentile": 8488.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8488.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9214.16, "90th_percentile": 10979.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 10891.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24707.44, "90th_percentile": 24707.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24707.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7315.28, "90th_percentile": 8397.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7357.82, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 955.48, "90th_percentile": 11327.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9644.74, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23178.91, "90th_percentile": 23178.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23178.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13185.95, "90th_percentile": 13185.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13185.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9230.35, "90th_percentile": 11381.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 9775.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23178.91, "90th_percentile": 24652.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23178.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "641", "type": "MS-DRG" } ], "description": "Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17295.38, "minimum": 7253.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17295.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15459.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16138.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14539.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13640.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7253.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14447.59 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15060.8, "90th_percentile": 15268.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15060.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5131.25, "90th_percentile": 6791.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5921.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18269.91, "90th_percentile": 18269.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18269.91, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3938.54, "90th_percentile": 13905.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3938.54, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12947.12, "90th_percentile": 16293.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15348.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5216.5, "90th_percentile": 6848.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5558.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 2640.62, "90th_percentile": 2640.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2640.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6660.1, "90th_percentile": 12586.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7601.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 11621.85, "90th_percentile": 11621.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11621.85, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6669.71, "90th_percentile": 13905.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13905.19, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5422.59, "90th_percentile": 6793.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6257.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15330.29, "90th_percentile": 15330.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15330.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 6257.54, "90th_percentile": 6257.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6257.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7003.65, "90th_percentile": 7003.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7003.65, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34469.64, "90th_percentile": 34469.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34469.64, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14423.08, "90th_percentile": 14423.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14423.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7428.28, "90th_percentile": 8661.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7428.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 817.88, "90th_percentile": 7177.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6315.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13638.56, "90th_percentile": 13638.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13638.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "642", "type": "MS-DRG" } ], "description": "Inborn And Other Disorders Of Metabolism", "standard_charges": [ { "billing_class": "facility", "maximum": 27466.78, "minimum": 12254.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27466.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24551.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25629.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23090.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21662.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12254.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22944.22 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 27440.72, "90th_percentile": 27440.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27440.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16691.65, "90th_percentile": 16691.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16691.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12014.06, "90th_percentile": 12014.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12014.06, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10090.53, "90th_percentile": 10090.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10090.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "643", "type": "MS-DRG" } ], "description": "Endocrine Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36677.71, "minimum": 13993.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36677.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32784.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34224.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30834.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28926.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13993.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30638.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10909.88, "90th_percentile": 13594.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 13379.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35442.89, "90th_percentile": 35442.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35442.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 12075.27, "90th_percentile": 12075.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12075.27, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32227.96, "90th_percentile": 34558.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32552.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12940.54, "90th_percentile": 13637.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13379.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5550.76, "90th_percentile": 5550.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5550.76, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4991.27, "90th_percentile": 9732.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4991.27, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11232.2, "90th_percentile": 13417.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11748.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 12306.17, "90th_percentile": 12306.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12306.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4861.95, "90th_percentile": 4861.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4861.95, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12224.97, "90th_percentile": 12224.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12224.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1174.75, "90th_percentile": 13539.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12160.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30590.44, "90th_percentile": 30590.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30590.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "644", "type": "MS-DRG" } ], "description": "Endocrine Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22872.39, "minimum": 9170.56, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22872.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20444.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21342.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19228.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18038.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9170.56 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19106.31 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 24161.93, "90th_percentile": 24161.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24161.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7948.18, "90th_percentile": 8716.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8197.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15122.4, "90th_percentile": 21117.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20298.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7692.81, "90th_percentile": 7692.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7692.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4528.1, "90th_percentile": 5856.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4528.1, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6470.28, "90th_percentile": 6470.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6470.28, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8219.62, "90th_percentile": 8714.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8219.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13489.55, "90th_percentile": 13489.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13489.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8710.51, "90th_percentile": 8710.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8710.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7942.66, "90th_percentile": 7942.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7942.66, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13632.8, "90th_percentile": 13632.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13632.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7195.38, "90th_percentile": 7195.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7195.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16585.49, "90th_percentile": 16585.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16585.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "645", "type": "MS-DRG" } ], "description": "Endocrine Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17240.05, "minimum": 7177.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17240.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15410.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16087.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14493.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13596.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7177.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14401.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 11071.3, "90th_percentile": 11071.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11071.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4732.67, "90th_percentile": 6043.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5621.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15295.23, "90th_percentile": 15404.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15295.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6191.39, "90th_percentile": 6191.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6191.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4954.12, "90th_percentile": 4954.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4954.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6753.18, "90th_percentile": 6753.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6753.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8827.3, "90th_percentile": 8827.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8827.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11722.97, "90th_percentile": 11722.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11722.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "650", "type": "MS-DRG" } ], "description": "Kidney Transplant With Hemodialysis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 101957.52, "minimum": 37720.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101957.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 91135.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 95139.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85713.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80410.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37720.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 85169.61 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "651", "type": "MS-DRG" } ], "description": "Kidney Transplant With Hemodialysis Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 76843.26, "minimum": 29989.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76843.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 68687.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 71704.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64600.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60603.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29989.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64190.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "652", "type": "MS-DRG" } ], "description": "Kidney Transplant", "standard_charges": [ { "billing_class": "facility", "maximum": 67968.73, "minimum": 26290.29, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67968.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 60754.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 63423.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57139.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53604.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26290.29 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 56777.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "653", "type": "MS-DRG" } ], "description": "Major Bladder Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 123362.62, "minimum": 41564.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 123362.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 110268.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 115112.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 103707.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 97292.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41564.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 103050.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "654", "type": "MS-DRG" } ], "description": "Major Bladder Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 62451.47, "minimum": 22949.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62451.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 55822.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 58275.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52501.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49253.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22949.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 52168.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19093.66, "90th_percentile": 19093.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19093.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 16741.39, "90th_percentile": 16741.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16741.39, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19743.92, "90th_percentile": 19743.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19743.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22172.56, "90th_percentile": 22172.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22172.56, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27621.83, "90th_percentile": 27621.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27621.83, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20444.59, "90th_percentile": 20444.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20444.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "655", "type": "MS-DRG" } ], "description": "Major Bladder Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 45970.51, "minimum": 17647.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45970.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41091.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 42896.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38646.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36255.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17647.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38401.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38648.17, "90th_percentile": 38648.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38648.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "656", "type": "MS-DRG" } ], "description": "Kidney And Ureter Procedures For Neoplasm With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 72096.16, "minimum": 25935.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72096.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 64443.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 67274.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60609.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56859.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25935.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 60225.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34102.23, "90th_percentile": 34102.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34102.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24040.07, "90th_percentile": 24040.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24040.07, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23771.55, "90th_percentile": 23771.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23771.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "657", "type": "MS-DRG" } ], "description": "Kidney And Ureter Procedures For Neoplasm With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 40455.47, "minimum": 15422.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40455.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36161.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37750.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34009.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31905.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15422.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33794.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14661.18, "90th_percentile": 14981.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14678.46, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12439.17, "90th_percentile": 12439.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12439.17, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13371.56, "90th_percentile": 14822.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13371.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33153.11, "90th_percentile": 33153.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33153.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11177.52, "90th_percentile": 11177.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11177.52, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14940.44, "90th_percentile": 14940.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14940.44, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14368.62, "90th_percentile": 14368.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14368.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35865.49, "90th_percentile": 35865.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35865.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 12609.36, "90th_percentile": 12609.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12609.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13321.83, "90th_percentile": 15257.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14801.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31907.66, "90th_percentile": 31907.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31907.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "658", "type": "MS-DRG" } ], "description": "Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33282.81, "minimum": 13261.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33282.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29750.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31057.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27980.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26249.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13261.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27802.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12234.98, "90th_percentile": 12234.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12234.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12217.91, "90th_percentile": 12217.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12217.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9830.67, "90th_percentile": 9830.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9830.67, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 75389.03, "90th_percentile": 75389.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75389.03, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12220.85, "90th_percentile": 12220.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12220.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 115180.88, "90th_percentile": 115180.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 115180.88, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 12362.9, "90th_percentile": 12362.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12362.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25871.35, "90th_percentile": 25871.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25871.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "659", "type": "MS-DRG" } ], "description": "Kidney And Ureter Procedures For Non-Neoplasm With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 57190.93, "minimum": 20942.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57190.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51120.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 53366.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48079.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45104.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20942.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47774.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 59628.57, "90th_percentile": 60643.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59628.57, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16926.34, "90th_percentile": 18564.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17978.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50760.82, "90th_percentile": 50760.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50760.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16399.07, "90th_percentile": 20510.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19341.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 20748.87, "90th_percentile": 20748.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20748.87, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17682.7, "90th_percentile": 19537.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17703.75, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 50916.39, "90th_percentile": 50916.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50916.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1594.52, "90th_percentile": 19457.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7718.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 188079.34, "90th_percentile": 188079.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 188079.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "660", "type": "MS-DRG" } ], "description": "Kidney And Ureter Procedures For Non-Neoplasm With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 29653.33, "minimum": 11474.67, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29653.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26505.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 27670.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24928.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23386.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11474.67 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 24770.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29627.4, "90th_percentile": 33611.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31330.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7963.94, "90th_percentile": 10999.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10206.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30462.82, "90th_percentile": 30462.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30462.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22530.5, "90th_percentile": 27229.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 26320.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 2303.06, "90th_percentile": 2303.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2303.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8436.88, "90th_percentile": 11058.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9244.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6998.75, "90th_percentile": 7702.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6998.75, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4990.4, "90th_percentile": 11629.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4990.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21511.27, "90th_percentile": 21511.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21511.27, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 29549.17, "90th_percentile": 29549.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29549.17, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 9911.55, "90th_percentile": 9911.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9911.55, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6255.44, "90th_percentile": 10153.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8934.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26139.38, "90th_percentile": 26139.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26139.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10405.93, "90th_percentile": 11007.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10929.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5513.2, "90th_percentile": 5513.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5513.2, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9862.36, "90th_percentile": 9862.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9862.36, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24821.49, "90th_percentile": 24821.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24821.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9332.58, "90th_percentile": 11117.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11019.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22014.01, "90th_percentile": 25172.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23206.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "661", "type": "MS-DRG" } ], "description": "Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22719.68, "minimum": 9251.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22719.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20308.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21200.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19099.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17918.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9251.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18978.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22912.5, "90th_percentile": 22912.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22912.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 740.71, "90th_percentile": 740.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 740.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17168.2, "90th_percentile": 20164.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20164.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7717.56, "90th_percentile": 9078.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8090.47, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19303.09, "90th_percentile": 20570.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19852.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3827.97, "90th_percentile": 3827.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3827.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18333.62, "90th_percentile": 19161.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18333.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8732.55, "90th_percentile": 8732.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8732.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18333.62, "90th_percentile": 18333.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18333.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "662", "type": "MS-DRG" } ], "description": "Minor Bladder Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 69035.44, "minimum": 24985.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69035.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 61707.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 64418.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58036.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54446.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24985.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57668.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24478.59, "90th_percentile": 24478.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24478.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24453.38, "90th_percentile": 24453.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24453.38, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2190.17, "90th_percentile": 2190.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2190.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "663", "type": "MS-DRG" } ], "description": "Minor Bladder Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 33800.68, "minimum": 13016.19, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33800.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30213.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31540.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28415.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26657.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13016.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28235.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31699.21, "90th_percentile": 31699.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31699.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12644.23, "90th_percentile": 12644.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12644.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11350.63, "90th_percentile": 11350.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11350.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12759.81, "90th_percentile": 12759.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12759.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "664", "type": "MS-DRG" } ], "description": "Minor Bladder Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 23897.05, "minimum": 9340.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23897.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21360.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22298.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20089.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18846.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9340.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19962.26 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9023.97, "90th_percentile": 9023.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9023.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19930.95, "90th_percentile": 19930.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19930.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "665", "type": "MS-DRG" } ], "description": "Prostatectomy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 75984.58, "minimum": 25449.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75984.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 67919.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 70903.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63878.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59926.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25449.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 63473.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24729.26, "90th_percentile": 24729.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24729.26, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "666", "type": "MS-DRG" } ], "description": "Prostatectomy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 36454.18, "minimum": 14795.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36454.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32584.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34016.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30646.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28750.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14795.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30451.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12522.11, "90th_percentile": 13381.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12522.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13304.1, "90th_percentile": 13304.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13304.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "667", "type": "MS-DRG" } ], "description": "Prostatectomy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22744.03, "minimum": 9801.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22744.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20329.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21223.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19120.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17937.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9801.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18999.09 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18971.13, "90th_percentile": 18971.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18971.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "668", "type": "MS-DRG" } ], "description": "Transurethral Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 64536.21, "minimum": 23886.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64536.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57686.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 60220.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54254.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50897.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23886.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53909.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22991.23, "90th_percentile": 22991.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22991.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22955.57, "90th_percentile": 22955.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22955.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 23205.55, "90th_percentile": 23205.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23205.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "669", "type": "MS-DRG" } ], "description": "Transurethral Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 34247.72, "minimum": 13263.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34247.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30612.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31957.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28791.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27010.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13263.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28608.63 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11455.82, "90th_percentile": 11455.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11455.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61231.77, "90th_percentile": 61231.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61231.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12551.18, "90th_percentile": 12619.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12551.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8696.39, "90th_percentile": 8696.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8696.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16717.36, "90th_percentile": 16717.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16717.36, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12589.4, "90th_percentile": 12884.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12590.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11361.35, "90th_percentile": 11361.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11361.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27010.07, "90th_percentile": 27010.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27010.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13151.05, "90th_percentile": 13151.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13151.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27010.07, "90th_percentile": 27010.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27010.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "670", "type": "MS-DRG" } ], "description": "Transurethral Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21148.38, "minimum": 8800.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21148.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18903.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19734.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17778.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16679.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8800.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17666.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8158.78, "90th_percentile": 8158.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8158.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "671", "type": "MS-DRG" } ], "description": "Urethral Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38144.99, "minimum": 15150.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38144.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34096.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35594.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32067.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30083.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15150.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31864.19 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34098.23, "90th_percentile": 34098.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34098.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15022.77, "90th_percentile": 15022.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15022.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "672", "type": "MS-DRG" } ], "description": "Urethral Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24217.95, "minimum": 9593.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24217.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21647.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22598.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20359.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19099.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9593.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20230.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "673", "type": "MS-DRG" } ], "description": "Other Kidney And Urinary Tract Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 92728.89, "minimum": 33839.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92728.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 82886.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 86527.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77954.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73132.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33839.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77460.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31160.04, "90th_percentile": 32500.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32352.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 334222.75, "90th_percentile": 334222.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 334222.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 15713.57, "90th_percentile": 15713.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15713.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32471.71, "90th_percentile": 32471.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32471.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 52671.84, "90th_percentile": 52671.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52671.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3005.79, "90th_percentile": 3005.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3005.79, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 31462.39, "90th_percentile": 31462.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31462.39, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30335.63, "90th_percentile": 44762.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30691.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 109861.39, "90th_percentile": 109861.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 109861.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46395.87, "90th_percentile": 46395.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46395.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32772.0, "90th_percentile": 39804.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32813.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 72148.08, "90th_percentile": 72148.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72148.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "674", "type": "MS-DRG" } ], "description": "Other Kidney And Urinary Tract Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 51084.99, "minimum": 19371.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 51084.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45662.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47668.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42945.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40289.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19371.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42673.54 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18323.7, "90th_percentile": 18323.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18323.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 45341.59, "90th_percentile": 207178.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48134.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18295.32, "90th_percentile": 18295.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18295.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8851.06, "90th_percentile": 8851.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8851.06, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5973.74, "90th_percentile": 5973.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5973.74, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16207.12, "90th_percentile": 18992.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18289.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42947.78, "90th_percentile": 42947.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42947.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17422.45, "90th_percentile": 17422.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17422.45, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42608.45, "90th_percentile": 42608.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42608.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6374.52, "90th_percentile": 6374.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6374.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38849.29, "90th_percentile": 43165.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42608.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "675", "type": "MS-DRG" } ], "description": "Other Kidney And Urinary Tract Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 34639.44, "minimum": 13957.4, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34639.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30962.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32322.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29120.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27319.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13957.4 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28935.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12689.59, "90th_percentile": 12689.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12689.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 79361.73, "90th_percentile": 79361.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79361.73, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11210.66, "90th_percentile": 11210.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11210.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "682", "type": "MS-DRG" } ], "description": "Renal Failure With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33240.76, "minimum": 12711.77, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33240.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29712.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31017.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27944.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26215.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12711.77 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27767.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 35115.92, "90th_percentile": 35115.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35115.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7564.99, "90th_percentile": 12386.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 11151.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30741.35, "90th_percentile": 30741.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30741.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 11647.69, "90th_percentile": 11647.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11647.69, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24415.2, "90th_percentile": 31317.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29500.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8482.5, "90th_percentile": 8482.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8482.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10080.7, "90th_percentile": 12335.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 11323.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 3400.13, "90th_percentile": 3400.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3400.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8558.92, "90th_percentile": 8558.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8558.92, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7144.19, "90th_percentile": 14864.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8023.98, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 26863.1, "90th_percentile": 26863.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26863.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10536.92, "90th_percentile": 10536.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10536.92, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8641.64, "90th_percentile": 12462.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 11515.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 10495.43, "90th_percentile": 12348.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11359.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8864.59, "90th_percentile": 16166.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8864.59, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11010.52, "90th_percentile": 11774.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11588.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27722.07, "90th_percentile": 27722.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27722.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8492.06, "90th_percentile": 8492.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8492.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10427.87, "90th_percentile": 12400.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 11059.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24302.85, "90th_percentile": 27722.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26214.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "683", "type": "MS-DRG" } ], "description": "Renal Failure With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 19672.25, "minimum": 8011.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19672.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17584.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18356.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16537.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15514.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8011.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16433.09 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 11819.0, "90th_percentile": 20477.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19653.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4564.84, "90th_percentile": 7650.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 6955.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20722.35, "90th_percentile": 20783.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20722.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 630.08, "90th_percentile": 630.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 630.08, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15207.08, "90th_percentile": 18043.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 17584.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8482.5, "90th_percentile": 8482.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8482.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 626.54, "90th_percentile": 7584.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 6042.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 2830.1, "90th_percentile": 2830.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2830.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4414.64, "90th_percentile": 4488.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4414.64, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20523.44, "90th_percentile": 20523.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20523.44, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4879.34, "90th_percentile": 8023.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4879.34, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19235.54, "90th_percentile": 19235.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19235.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 5921.82, "90th_percentile": 5921.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5921.82, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5595.97, "90th_percentile": 7632.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 7584.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14228.48, "90th_percentile": 14228.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14228.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 4617.75, "90th_percentile": 4617.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4617.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 630.08, "90th_percentile": 7642.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 630.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 6330.6, "90th_percentile": 6330.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6330.6, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5390.51, "90th_percentile": 8864.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5481.17, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 626.54, "90th_percentile": 626.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 626.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16165.52, "90th_percentile": 16165.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16165.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5111.69, "90th_percentile": 8406.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8406.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3649.21, "90th_percentile": 7932.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 7169.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15514.86, "90th_percentile": 16407.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16165.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "684", "type": "MS-DRG" } ], "description": "Renal Failure Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 13444.58, "minimum": 5872.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13444.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12017.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12545.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11302.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10603.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5872.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11230.85 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19002.5, "90th_percentile": 19002.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19002.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4879.34, "90th_percentile": 4879.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4879.34, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4579.38, "90th_percentile": 5018.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4579.38, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11211.39, "90th_percentile": 11211.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11211.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4776.66, "90th_percentile": 4776.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4776.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10601.56, "90th_percentile": 10601.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10601.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "686", "type": "MS-DRG" } ], "description": "Kidney And Urinary Tract Neoplasms With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41730.21, "minimum": 15217.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41730.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37300.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38939.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35081.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32911.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15217.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34859.09 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14828.74, "90th_percentile": 14828.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14828.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22457.7, "90th_percentile": 22457.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22457.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15144.85, "90th_percentile": 15144.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15144.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 49890.39, "90th_percentile": 49890.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49890.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36074.54, "90th_percentile": 36074.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36074.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15239.42, "90th_percentile": 15239.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15239.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "687", "type": "MS-DRG" } ], "description": "Kidney And Urinary Tract Neoplasms With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23295.09, "minimum": 9347.62, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23295.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20822.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21737.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19583.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18372.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9347.62 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19459.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8819.76, "90th_percentile": 8819.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8819.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30214.89, "90th_percentile": 30214.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30214.89, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8262.59, "90th_percentile": 8262.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8262.59, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "688", "type": "MS-DRG" } ], "description": "Kidney And Urinary Tract Neoplasms Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16027.27, "minimum": 7347.92, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16027.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14326.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14955.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13473.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12640.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7347.92 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13388.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6577.22, "90th_percentile": 6577.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6577.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "689", "type": "MS-DRG" } ], "description": "Kidney And Urinary Tract Infections With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25902.12, "minimum": 10221.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25902.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23152.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24169.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21775.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20428.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10221.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21637.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 26299.05, "90th_percentile": 27362.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26299.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5544.22, "90th_percentile": 9770.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 8878.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20633.72, "90th_percentile": 41837.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22910.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7579.88, "90th_percentile": 9928.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 9094.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7002.18, "90th_percentile": 7002.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7002.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 25436.47, "90th_percentile": 25436.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25436.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7756.82, "90th_percentile": 7756.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7756.82, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11905.96, "90th_percentile": 11905.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11905.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7565.18, "90th_percentile": 9928.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 8354.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7905.48, "90th_percentile": 10018.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9745.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7735.74, "90th_percentile": 11905.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7735.74, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8650.31, "90th_percentile": 8650.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8650.31, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20426.42, "90th_percentile": 20426.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20426.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7831.15, "90th_percentile": 8843.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 8115.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21416.82, "90th_percentile": 21601.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21416.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "690", "type": "MS-DRG" } ], "description": "Kidney And Urinary Tract Infections Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17762.34, "minimum": 7497.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17762.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15877.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16574.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14932.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14008.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7497.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14837.67 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 14422.74, "90th_percentile": 18525.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17762.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3129.59, "90th_percentile": 6977.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 6365.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17762.34, "90th_percentile": 17762.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17762.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 5125.93, "90th_percentile": 5125.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5125.93, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10907.25, "90th_percentile": 15877.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14481.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5275.56, "90th_percentile": 5275.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5275.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5060.5, "90th_percentile": 7282.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 6702.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 9179.91, "90th_percentile": 9179.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9179.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4515.12, "90th_percentile": 4515.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4515.12, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4990.4, "90th_percentile": 4990.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4990.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6997.18, "90th_percentile": 6997.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6997.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 6503.73, "90th_percentile": 7368.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6503.73, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5603.87, "90th_percentile": 5603.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5603.87, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5204.11, "90th_percentile": 6966.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 6380.5, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15746.21, "90th_percentile": 15746.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15746.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 47972.17, "90th_percentile": 47972.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47972.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 6691.8, "90th_percentile": 6728.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6691.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 6206.96, "90th_percentile": 7203.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6206.96, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5603.87, "90th_percentile": 5603.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5603.87, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7188.0, "90th_percentile": 7218.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7188.0, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14008.58, "90th_percentile": 14008.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14008.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5228.04, "90th_percentile": 5228.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5228.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5086.05, "90th_percentile": 7003.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 5790.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13588.58, "90th_percentile": 14941.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14814.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "693", "type": "MS-DRG" } ], "description": "Urinary Stones With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32539.21, "minimum": 11651.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32539.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29085.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30363.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27354.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25662.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11651.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27181.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11978.83, "90th_percentile": 11978.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11978.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29087.45, "90th_percentile": 29087.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29087.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12079.87, "90th_percentile": 12079.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12079.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "694", "type": "MS-DRG" } ], "description": "Urinary Stones Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17293.16, "minimum": 7281.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17293.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15457.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16136.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14537.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13638.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7281.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14445.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 400.0, "90th_percentile": 400.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 400.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5239.12, "90th_percentile": 7217.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6778.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18269.91, "90th_percentile": 18269.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18269.91, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5869.04, "90th_percentile": 5869.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5869.04, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16104.58, "90th_percentile": 16104.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16104.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7072.47, "90th_percentile": 7072.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7072.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4979.92, "90th_percentile": 4979.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4979.92, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 16983.73, "90th_percentile": 16983.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16983.73, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6769.63, "90th_percentile": 6773.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6773.56, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17329.7, "90th_percentile": 17329.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17329.7, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14626.05, "90th_percentile": 14626.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14626.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7203.95, "90th_percentile": 7203.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7203.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14423.08, "90th_percentile": 14423.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14423.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "695", "type": "MS-DRG" } ], "description": "Kidney And Urinary Tract Signs And Symptoms With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24957.13, "minimum": 10093.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24957.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22308.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23288.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20980.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19682.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10093.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20847.79 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1377.68, "90th_percentile": 1377.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1377.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "696", "type": "MS-DRG" } ], "description": "Kidney And Urinary Tract Signs And Symptoms Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15308.01, "minimum": 6561.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15308.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13683.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14284.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12869.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12072.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6561.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12787.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5604.13, "90th_percentile": 36476.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5880.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5490.27, "90th_percentile": 5967.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5490.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4968.25, "90th_percentile": 4968.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4968.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5528.55, "90th_percentile": 7197.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5956.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "697", "type": "MS-DRG" } ], "description": "Urethral Stricture", "standard_charges": [ { "billing_class": "facility", "maximum": 22170.84, "minimum": 9580.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22170.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19817.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20688.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18638.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17485.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9580.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18520.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8593.56, "90th_percentile": 8593.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8593.56, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "698", "type": "MS-DRG" } ], "description": "Other Kidney And Urinary Tract Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 37200.0, "minimum": 14058.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37200.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33251.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34712.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31273.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29338.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14058.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31074.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30635.05, "90th_percentile": 39301.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32750.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1394.67, "90th_percentile": 13580.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 12376.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 10517.13, "90th_percentile": 10517.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10517.13, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5755.34, "90th_percentile": 5755.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5755.34, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 11383.38, "90th_percentile": 11383.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11383.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8827.42, "90th_percentile": 13551.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 12362.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 11570.84, "90th_percentile": 26181.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11570.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18186.39, "90th_percentile": 18186.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18186.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10768.07, "90th_percentile": 10768.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10768.07, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 37078.94, "90th_percentile": 37078.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37078.94, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8827.6, "90th_percentile": 13782.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 11415.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13201.84, "90th_percentile": 13648.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13557.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 515.95, "90th_percentile": 515.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 515.95, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6885.24, "90th_percentile": 14327.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11896.15, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12409.57, "90th_percentile": 12409.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12409.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30536.92, "90th_percentile": 30536.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30536.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7573.75, "90th_percentile": 7573.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7573.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1452.64, "90th_percentile": 13908.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11566.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30536.92, "90th_percentile": 30536.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30536.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "699", "type": "MS-DRG" } ], "description": "Other Kidney And Urinary Tract Diagnoses With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22569.19, "minimum": 9092.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22569.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20173.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21059.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18973.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17799.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9092.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18853.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 14145.84, "90th_percentile": 14145.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14145.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5773.21, "90th_percentile": 8590.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 7850.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7763.56, "90th_percentile": 7763.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7763.56, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16306.98, "90th_percentile": 20032.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16306.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5723.03, "90th_percentile": 8585.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 8104.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8326.73, "90th_percentile": 8326.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8326.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6101.05, "90th_percentile": 6101.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6101.05, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6997.46, "90th_percentile": 6997.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6997.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22791.99, "90th_percentile": 22791.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22791.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 79132.35, "90th_percentile": 79132.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79132.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8998.01, "90th_percentile": 8998.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8998.01, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4487.43, "90th_percentile": 4487.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4487.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5711.54, "90th_percentile": 8572.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7264.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14454.24, "90th_percentile": 22844.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18676.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5457.65, "90th_percentile": 5457.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5457.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7092.51, "90th_percentile": 8996.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7611.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17801.33, "90th_percentile": 18384.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17801.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "700", "type": "MS-DRG" } ], "description": "Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15361.13, "minimum": 6568.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15361.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13730.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14333.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12913.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12114.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6568.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12831.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14213.32, "90th_percentile": 14213.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14213.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2176.9, "90th_percentile": 2176.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2176.9, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5813.75, "90th_percentile": 5813.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5813.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6438.6, "90th_percentile": 6438.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6438.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "707", "type": "MS-DRG" } ], "description": "Major Male Pelvic Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 42945.21, "minimum": 16744.55, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42945.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38386.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40073.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36103.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33869.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16744.55 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35874.02 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12514.57, "90th_percentile": 12514.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12514.57, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11327.84, "90th_percentile": 11327.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11327.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12694.24, "90th_percentile": 12694.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12694.24, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "708", "type": "MS-DRG" } ], "description": "Major Male Pelvic Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32806.99, "minimum": 13124.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32806.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29324.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30613.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27580.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25873.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13124.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27405.13 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 35871.13, "90th_percentile": 35871.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35871.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "709", "type": "MS-DRG" } ], "description": "Penis Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 49728.36, "minimum": 19282.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49728.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44450.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46402.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41805.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39219.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19282.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41540.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "710", "type": "MS-DRG" } ], "description": "Penis Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33225.27, "minimum": 12092.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33225.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29698.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31003.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27931.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26203.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12092.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27754.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "711", "type": "MS-DRG" } ], "description": "Testes Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 42283.49, "minimum": 17393.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42283.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37795.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39455.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35546.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33347.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17393.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35321.26 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13395.43, "90th_percentile": 13395.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13395.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "712", "type": "MS-DRG" } ], "description": "Testes Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 23671.32, "minimum": 9750.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23671.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21158.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22088.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19899.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18668.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9750.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19773.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "713", "type": "MS-DRG" } ], "description": "Transurethral Prostatectomy With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31999.21, "minimum": 12885.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31999.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28602.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29859.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26900.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12885.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26730.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10769.69, "90th_percentile": 11838.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10769.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27533.29, "90th_percentile": 27533.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27533.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17413.72, "90th_percentile": 17413.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17413.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10433.29, "90th_percentile": 11731.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11586.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11888.34, "90th_percentile": 11926.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11888.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24706.41, "90th_percentile": 24706.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24706.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "714", "type": "MS-DRG" } ], "description": "Transurethral Prostatectomy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20794.29, "minimum": 9422.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20794.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18587.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19403.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17481.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16399.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9422.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17370.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7973.59, "90th_percentile": 7973.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7973.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "715", "type": "MS-DRG" } ], "description": "Other Male Reproductive System O.R. Procedures For Malignancy With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 49976.22, "minimum": 18585.05, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49976.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44671.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46634.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42013.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39414.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18585.05 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41747.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47090.07, "90th_percentile": 47090.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47090.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18006.87, "90th_percentile": 18006.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18006.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "716", "type": "MS-DRG" } ], "description": "Other Male Reproductive System O.R. Procedures For Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31408.32, "minimum": 12634.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31408.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28074.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29307.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26404.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24770.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12634.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26236.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "717", "type": "MS-DRG" } ], "description": "Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41061.86, "minimum": 15891.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41061.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36703.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38315.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34519.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32384.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15891.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34300.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22789.03, "90th_percentile": 22789.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22789.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38690.89, "90th_percentile": 38690.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38690.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5281.4, "90th_percentile": 5281.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5281.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5834.68, "90th_percentile": 5834.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5834.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14646.55, "90th_percentile": 14646.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14646.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15438.1, "90th_percentile": 15438.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15438.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14974.5, "90th_percentile": 15009.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14974.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "718", "type": "MS-DRG" } ], "description": "Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27260.97, "minimum": 11640.86, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27260.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24367.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25437.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22917.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21499.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11640.86 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22772.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "722", "type": "MS-DRG" } ], "description": "Malignancy, Male Reproductive System With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38260.07, "minimum": 15264.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38260.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34199.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35701.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32164.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30174.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15264.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31960.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1486.67, "90th_percentile": 1486.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1486.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "723", "type": "MS-DRG" } ], "description": "Malignancy, Male Reproductive System With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 24850.9, "minimum": 10084.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24850.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22213.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23189.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20891.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19599.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10084.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20759.05 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9343.55, "90th_percentile": 9343.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9343.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9349.01, "90th_percentile": 9349.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9349.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7207.71, "90th_percentile": 7545.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7207.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9434.54, "90th_percentile": 9434.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9434.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "724", "type": "MS-DRG" } ], "description": "Malignancy, Male Reproductive System Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16124.65, "minimum": 6302.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16124.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14413.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15046.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13555.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12716.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6302.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13469.63 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "725", "type": "MS-DRG" } ], "description": "Benign Prostatic Hypertrophy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27953.67, "minimum": 10298.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27953.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24986.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26084.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23499.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22046.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10298.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23350.93 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10396.69, "90th_percentile": 10396.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10396.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "726", "type": "MS-DRG" } ], "description": "Benign Prostatic Hypertrophy Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 16472.1, "minimum": 6817.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16472.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14723.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15370.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13847.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12991.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6817.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13759.87 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4625.13, "90th_percentile": 4625.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4625.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6429.12, "90th_percentile": 6429.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6429.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "727", "type": "MS-DRG" } ], "description": "Inflammation Of The Male Reproductive System With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32517.08, "minimum": 12726.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32517.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29065.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30342.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27336.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25645.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12726.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27162.95 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10550.13, "90th_percentile": 10550.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10550.13, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "728", "type": "MS-DRG" } ], "description": "Inflammation Of The Male Reproductive System Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18083.24, "minimum": 7510.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18083.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16163.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16873.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15202.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14261.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7510.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15105.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6419.2, "90th_percentile": 6419.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6419.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5281.4, "90th_percentile": 10910.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5281.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5759.83, "90th_percentile": 5759.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5759.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 48936.06, "90th_percentile": 48936.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48936.06, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7093.51, "90th_percentile": 7093.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7093.51, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5928.67, "90th_percentile": 5928.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5928.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "729", "type": "MS-DRG" } ], "description": "Other Male Reproductive System Diagnoses With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24361.8, "minimum": 9432.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24361.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21776.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22732.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20480.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19213.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9432.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20350.49 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9183.25, "90th_percentile": 9183.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9183.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5281.4, "90th_percentile": 5281.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5281.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "730", "type": "MS-DRG" } ], "description": "Other Male Reproductive System Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 13431.3, "minimum": 6429.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13431.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12005.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12533.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11291.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10592.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6429.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11219.76 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "734", "type": "MS-DRG" } ], "description": "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 46534.85, "minimum": 17751.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46534.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41595.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43422.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39120.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36700.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17751.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38872.61 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41303.2, "90th_percentile": 41303.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41303.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5893.94, "90th_percentile": 5893.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5893.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13606.05, "90th_percentile": 13606.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13606.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15984.73, "90th_percentile": 15984.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15984.73, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16891.55, "90th_percentile": 16891.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16891.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "735", "type": "MS-DRG" } ], "description": "Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 26862.61, "minimum": 11659.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26862.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24011.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25066.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22582.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21185.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11659.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22439.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9482.66, "90th_percentile": 9482.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9482.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22406.17, "90th_percentile": 22406.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22406.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "736", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 87136.39, "minimum": 28969.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87136.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77887.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 81309.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73253.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68721.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28969.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72788.87 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30666.27, "90th_percentile": 30666.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30666.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 77342.34, "90th_percentile": 77342.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77342.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28338.69, "90th_percentile": 28338.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28338.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 106840.14, "90th_percentile": 106840.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 106840.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30854.29, "90th_percentile": 30854.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30854.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 165435.09, "90th_percentile": 165435.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 165435.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "737", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 44224.38, "minimum": 17212.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44224.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39530.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41266.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37178.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34878.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17212.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36942.57 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 44421.06, "90th_percentile": 44421.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44421.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15966.88, "90th_percentile": 16587.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15974.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39252.57, "90th_percentile": 39252.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39252.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16597.25, "90th_percentile": 16597.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16597.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 35159.18, "90th_percentile": 35159.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35159.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26163.09, "90th_percentile": 26163.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26163.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16763.42, "90th_percentile": 16763.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16763.42, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 116272.39, "90th_percentile": 116272.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 116272.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 176757.8, "90th_percentile": 176757.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 176757.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 16001.33, "90th_percentile": 16001.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16001.33, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15979.3, "90th_percentile": 15995.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15979.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37180.23, "90th_percentile": 240662.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37413.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 44711.34, "90th_percentile": 44711.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44711.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15972.5, "90th_percentile": 15972.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15972.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16885.96, "90th_percentile": 16885.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16885.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33698.21, "90th_percentile": 33698.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33698.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "738", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33568.3, "minimum": 12614.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33568.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30005.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31323.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28220.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26474.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12614.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28041.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9918.07, "90th_percentile": 9918.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9918.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12379.73, "90th_percentile": 12379.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12379.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10824.87, "90th_percentile": 10824.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10824.87, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26966.92, "90th_percentile": 26966.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26966.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 34130.56, "90th_percentile": 34130.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34130.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27998.94, "90th_percentile": 27998.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27998.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "739", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 88096.87, "minimum": 29033.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88096.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 78746.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 82205.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74060.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69479.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29033.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73591.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28081.39, "90th_percentile": 28081.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28081.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30883.15, "90th_percentile": 31151.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30883.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28943.0, "90th_percentile": 28943.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28943.0, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 184066.35, "90th_percentile": 184066.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 184066.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "460", "type": "MS-DRG" } ], "description": "Spinal Fusion Except Cervical Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 85609.49, "minimum": 63844.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85609.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 72360.58 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 75539.29 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68055.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 63844.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 67623.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "454", "type": "MS-DRG" } ], "description": "Combined Anterior And Posterior Spinal Fusion With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 143145.89, "minimum": 106753.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 143145.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 120992.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 126307.71 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 113793.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 106753.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 113072.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "989", "type": "MS-DRG" } ], "description": "Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25570.16, "minimum": 10523.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25570.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22856.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23860.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21496.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20166.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10523.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21359.88 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8785.19, "90th_percentile": 8785.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8785.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 12918.06, "90th_percentile": 12918.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12918.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11555.85, "90th_percentile": 11555.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11555.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5215.44, "90th_percentile": 5215.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5215.44, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "988", "type": "MS-DRG" } ], "description": "Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 37976.8, "minimum": 13974.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37976.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33945.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35437.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31926.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29951.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13974.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31723.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 43394.04, "90th_percentile": 43394.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43394.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12347.1, "90th_percentile": 15147.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12347.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12261.83, "90th_percentile": 12261.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12261.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11952.78, "90th_percentile": 13822.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11952.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 17792.05, "90th_percentile": 17792.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17792.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 11906.95, "90th_percentile": 11906.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11906.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10460.04, "90th_percentile": 10460.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10460.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 11529.19, "90th_percentile": 11529.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11529.19, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13622.26, "90th_percentile": 13864.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13859.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1175.81, "90th_percentile": 1175.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1175.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "987", "type": "MS-DRG" } ], "description": "Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 77524.89, "minimum": 27834.91, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77524.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 69296.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 72340.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 65173.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 61141.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27834.91 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 64759.96 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20518.51, "90th_percentile": 24811.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20518.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 25920.18, "90th_percentile": 25920.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25920.18, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69290.41, "90th_percentile": 69290.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69290.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8359.49, "90th_percentile": 8359.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8359.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25642.16, "90th_percentile": 27134.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25642.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 11057.52, "90th_percentile": 11057.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11057.52, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37908.55, "90th_percentile": 37908.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37908.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 17041.83, "90th_percentile": 17041.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17041.83, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25030.4, "90th_percentile": 27289.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26007.73, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 68719.47, "90th_percentile": 69427.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68719.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 2452.65, "90th_percentile": 2452.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2452.65, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36092.91, "90th_percentile": 36092.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36092.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28276.66, "90th_percentile": 28276.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28276.66, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2452.65, "90th_percentile": 24243.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23560.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "983", "type": "MS-DRG" } ], "description": "Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36916.72, "minimum": 14521.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36916.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32998.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34447.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31035.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29115.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14521.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30838.16 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13518.44, "90th_percentile": 13518.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13518.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32766.78, "90th_percentile": 33000.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33000.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13461.88, "90th_percentile": 13461.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13461.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 34683.28, "90th_percentile": 34683.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34683.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8298.54, "90th_percentile": 8298.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8298.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13499.44, "90th_percentile": 13499.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13499.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14367.65, "90th_percentile": 14367.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14367.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "982", "type": "MS-DRG" } ], "description": "Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 54187.75, "minimum": 20302.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54187.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48436.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 50563.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45554.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42736.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20302.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45265.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 53612.76, "90th_percentile": 53612.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53612.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16976.92, "90th_percentile": 22324.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17851.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48089.51, "90th_percentile": 50650.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48089.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17218.08, "90th_percentile": 19400.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19373.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30144.11, "90th_percentile": 30144.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30144.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8103.68, "90th_percentile": 20094.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9397.51, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 47898.8, "90th_percentile": 47898.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47898.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19356.62, "90th_percentile": 19437.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19356.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 17833.65, "90th_percentile": 17833.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17833.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 1758.8, "90th_percentile": 1758.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1758.8, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16564.53, "90th_percentile": 16564.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16564.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19573.66, "90th_percentile": 19573.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19573.66, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 55087.59, "90th_percentile": 55087.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55087.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7773.39, "90th_percentile": 18543.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14522.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41360.36, "90th_percentile": 41360.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41360.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "981", "type": "MS-DRG" } ], "description": "Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 105217.41, "minimum": 37646.24, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 105217.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 94049.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 98181.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88453.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82981.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37646.24 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 87892.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 123936.16, "90th_percentile": 123936.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 123936.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3369.7, "90th_percentile": 36747.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34503.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 49718.34, "90th_percentile": 49718.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49718.34, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61003.73, "90th_percentile": 326880.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 216588.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22268.82, "90th_percentile": 35830.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29727.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 39265.05, "90th_percentile": 39265.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39265.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2528.3, "90th_percentile": 2528.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2528.3, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11456.6, "90th_percentile": 42896.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16576.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 35288.73, "90th_percentile": 35288.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35288.73, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 34138.68, "90th_percentile": 34138.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34138.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27767.17, "90th_percentile": 35831.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 33846.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 203506.83, "90th_percentile": 203506.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 203506.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 34833.3, "90th_percentile": 36773.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36732.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 40899.9, "90th_percentile": 40899.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40899.9, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 48732.16, "90th_percentile": 48732.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48732.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16000.0, "90th_percentile": 16000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16000.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 17366.2, "90th_percentile": 17397.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17366.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3369.7, "90th_percentile": 37066.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34637.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 299411.13, "90th_percentile": 299411.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 299411.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "977", "type": "MS-DRG" } ], "description": "Hiv With Or Without Other Related Condition", "standard_charges": [ { "billing_class": "facility", "maximum": 31908.48, "minimum": 11288.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31908.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28521.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29774.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26824.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25165.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11288.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26654.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11754.79, "90th_percentile": 11754.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11754.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5589.52, "90th_percentile": 5589.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5589.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "976", "type": "MS-DRG" } ], "description": "Hiv With Major Related Condition Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22195.18, "minimum": 8220.8, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22195.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19839.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20710.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18658.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17504.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8220.8 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18540.61 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "975", "type": "MS-DRG" } ], "description": "Hiv With Major Related Condition With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 31454.79, "minimum": 11267.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31454.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28116.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29351.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26443.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24807.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11267.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26275.57 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29293.36, "90th_percentile": 29293.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29293.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 2146.59, "90th_percentile": 2146.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2146.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5922.56, "90th_percentile": 5922.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5922.56, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "974", "type": "MS-DRG" } ], "description": "Hiv With Major Related Condition With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 66083.17, "minimum": 23622.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66083.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 59069.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 61663.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55554.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52117.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23622.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 55202.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40440.81, "90th_percentile": 40440.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40440.81, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 136372.56, "90th_percentile": 136372.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 136372.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37868.57, "90th_percentile": 37868.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37868.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 93162.16, "90th_percentile": 93162.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 93162.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 15775.86, "90th_percentile": 15775.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15775.86, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10192.0, "90th_percentile": 17436.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10192.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 332054.6, "90th_percentile": 332054.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 332054.6, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11060.96, "90th_percentile": 11060.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11060.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 55205.88, "90th_percentile": 55205.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55205.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "970", "type": "MS-DRG" } ], "description": "Hiv With Extensive O.R. Procedures Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 58717.97, "minimum": 21692.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58717.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52485.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 54791.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49362.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46308.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21692.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49049.71 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "969", "type": "MS-DRG" } ], "description": "Hiv With Extensive O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 139954.23, "minimum": 48747.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 139954.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 125099.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 130594.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 117656.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110377.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48747.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 116909.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 123599.45, "90th_percentile": 123599.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 123599.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 263819.2, "90th_percentile": 263819.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 263819.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "965", "type": "MS-DRG" } ], "description": "Other Multiple Significant Trauma Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20194.54, "minimum": 8514.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20194.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18051.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18844.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16977.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15926.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8514.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16869.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "964", "type": "MS-DRG" } ], "description": "Other Multiple Significant Trauma With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 33200.93, "minimum": 13112.48, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33200.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29676.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30980.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27911.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26184.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13112.48 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27734.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12232.4, "90th_percentile": 12232.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12232.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31280.09, "90th_percentile": 31280.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31280.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11218.78, "90th_percentile": 12130.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11218.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7332.82, "90th_percentile": 7332.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7332.82, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 20815.85, "90th_percentile": 20815.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20815.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12193.72, "90th_percentile": 12193.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12193.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27124.7, "90th_percentile": 27124.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27124.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8953.76, "90th_percentile": 8953.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8953.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9421.11, "90th_percentile": 9421.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9421.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "963", "type": "MS-DRG" } ], "description": "Other Multiple Significant Trauma With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 60121.07, "minimum": 22440.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 60121.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 53739.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 56100.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50542.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47415.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22440.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 50221.78 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21694.06, "90th_percentile": 21800.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21694.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46690.69, "90th_percentile": 46690.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46690.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7542.4, "90th_percentile": 7542.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7542.4, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 23986.29, "90th_percentile": 23986.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23986.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 33961.27, "90th_percentile": 33961.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33961.27, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 26499.14, "90th_percentile": 26499.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26499.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17986.41, "90th_percentile": 21375.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17986.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 19838.21, "90th_percentile": 19838.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19838.21, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21563.3, "90th_percentile": 21563.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21563.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "959", "type": "MS-DRG" } ], "description": "Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 58507.72, "minimum": 24073.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 58507.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52297.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 54595.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49186.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46143.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24073.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 48874.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 112875.41, "90th_percentile": 112875.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 112875.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "958", "type": "MS-DRG" } ], "description": "Other O.R. Procedures For Multiple Significant Trauma With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 90947.34, "minimum": 33934.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 90947.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 81294.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 84865.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 76457.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71727.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33934.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75972.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 90953.98, "90th_percentile": 90953.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90953.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41314.07, "90th_percentile": 41314.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41314.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 90867.68, "90th_percentile": 90867.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90867.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 78306.69, "90th_percentile": 238411.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 80724.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 17552.39, "90th_percentile": 17552.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17552.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 45424.65, "90th_percentile": 45424.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45424.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 18907.64, "90th_percentile": 18907.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18907.64, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 161987.16, "90th_percentile": 161987.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 161987.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 20815.85, "90th_percentile": 20815.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20815.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 74739.72, "90th_percentile": 74739.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74739.72, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32008.66, "90th_percentile": 32008.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32008.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 81693.11, "90th_percentile": 81693.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 81693.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4789.8, "90th_percentile": 4789.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4789.8, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 233183.68, "90th_percentile": 233183.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 233183.68, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32174.72, "90th_percentile": 32174.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32174.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 238004.71, "90th_percentile": 238004.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 238004.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "957", "type": "MS-DRG" } ], "description": "Other O.R. Procedures For Multiple Significant Trauma With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 165179.14, "minimum": 60385.32, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 165179.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 147646.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 154132.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 138862.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 130271.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60385.32 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 137981.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 136955.95, "90th_percentile": 136955.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 136955.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 55530.45, "90th_percentile": 62946.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56781.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38802.24, "90th_percentile": 38802.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38802.24, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 265093.81, "90th_percentile": 335711.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 265093.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 29427.27, "90th_percentile": 29427.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29427.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 57506.53, "90th_percentile": 57506.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57506.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 26744.16, "90th_percentile": 26744.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26744.16, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 11606.15, "90th_percentile": 11606.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11606.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 57216.74, "90th_percentile": 57216.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57216.74, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 57187.64, "90th_percentile": 57187.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57187.64, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41325.6, "90th_percentile": 41325.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41325.6, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 52106.76, "90th_percentile": 57691.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57286.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 274858.72, "90th_percentile": 274858.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 274858.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "956", "type": "MS-DRG" } ], "description": "Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma", "standard_charges": [ { "billing_class": "facility", "maximum": 84589.11, "minimum": 30433.35, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 84589.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 75610.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 78932.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71112.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66712.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30433.35 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 70661.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26250.07, "90th_percentile": 26250.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26250.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 83458.68, "90th_percentile": 83458.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83458.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46772.64, "90th_percentile": 46772.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46772.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13078.24, "90th_percentile": 13078.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13078.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28335.14, "90th_percentile": 28335.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28335.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 250035.63, "90th_percentile": 250035.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 250035.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24166.39, "90th_percentile": 24166.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24166.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 84710.75, "90th_percentile": 84710.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84710.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 16236.26, "90th_percentile": 16236.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16236.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13786.99, "90th_percentile": 13786.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13786.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 67479.87, "90th_percentile": 67479.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67479.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 75138.82, "90th_percentile": 75138.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75138.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "955", "type": "MS-DRG" } ], "description": "Craniotomy For Multiple Significant Trauma", "standard_charges": [ { "billing_class": "facility", "maximum": 151108.25, "minimum": 53483.06, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 151108.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 135069.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 141002.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 127033.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 119174.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53483.06 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 126227.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50073.31, "90th_percentile": 50665.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50073.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 58451.04, "90th_percentile": 58451.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58451.04, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "951", "type": "MS-DRG" } ], "description": "Other Factors Influencing Health Status", "standard_charges": [ { "billing_class": "facility", "maximum": 12546.06, "minimum": 5528.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12546.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11214.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 11707.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10547.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9894.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5528.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10480.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3186.0, "90th_percentile": 4641.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3295.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4374.74, "90th_percentile": 4374.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4374.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2222.35, "90th_percentile": 2313.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2222.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3468.0, "90th_percentile": 10679.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4470.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 1810.85, "90th_percentile": 10566.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2055.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2210.29, "90th_percentile": 2210.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2210.29, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2011.61, "90th_percentile": 2011.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2011.61, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3035.29, "90th_percentile": 3035.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3035.29, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 5272.94, "90th_percentile": 5272.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5272.94, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5168.56, "90th_percentile": 5168.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5168.56, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3690.0, "90th_percentile": 7009.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5834.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46.2, "90th_percentile": 46.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46.2, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9981.34, "90th_percentile": 10465.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10465.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "950", "type": "MS-DRG" } ], "description": "Aftercare Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 12970.98, "minimum": 6085.2, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12970.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 11594.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12103.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10904.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10229.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6085.2 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 10835.23 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "949", "type": "MS-DRG" } ], "description": "Aftercare With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 23877.14, "minimum": 10449.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23877.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21342.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22280.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20072.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18831.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10449.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19945.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "948", "type": "MS-DRG" } ], "description": "Signs And Symptoms Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 17583.08, "minimum": 7427.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17583.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 15716.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16407.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14781.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13867.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7427.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 14687.92 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18576.2, "90th_percentile": 30291.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18576.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 563.17, "90th_percentile": 563.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 563.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18716.49, "90th_percentile": 18716.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18716.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15605.57, "90th_percentile": 15605.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15605.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6264.05, "90th_percentile": 6264.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6264.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5196.72, "90th_percentile": 6894.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5210.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 9629.89, "90th_percentile": 9629.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9629.89, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5843.39, "90th_percentile": 9110.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5843.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7222.16, "90th_percentile": 7222.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7222.16, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6923.31, "90th_percentile": 6923.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6923.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14781.67, "90th_percentile": 14781.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14781.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 4859.98, "90th_percentile": 4859.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4859.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6455.55, "90th_percentile": 6455.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6455.55, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6121.64, "90th_percentile": 14403.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9457.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6941.93, "90th_percentile": 7316.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6941.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14664.88, "90th_percentile": 14664.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14664.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "947", "type": "MS-DRG" } ], "description": "Signs And Symptoms With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28462.68, "minimum": 11068.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28462.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25441.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26559.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23927.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22447.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11068.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23776.13 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30072.64, "90th_percentile": 30072.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30072.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10584.14, "90th_percentile": 10584.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10584.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25263.54, "90th_percentile": 25443.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25263.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10580.55, "90th_percentile": 10851.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10580.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9028.03, "90th_percentile": 9028.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9028.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6455.55, "90th_percentile": 6455.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6455.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8498.05, "90th_percentile": 10580.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10040.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25233.96, "90th_percentile": 25233.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25233.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9973.82, "90th_percentile": 9973.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9973.82, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10677.23, "90th_percentile": 10850.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10677.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22449.33, "90th_percentile": 22807.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22449.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "946", "type": "MS-DRG" } ], "description": "Rehabilitation Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24707.05, "minimum": 10116.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24707.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22084.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23054.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20770.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19485.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10116.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20638.89 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "945", "type": "MS-DRG" } ], "description": "Rehabilitation With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 33780.76, "minimum": 13236.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33780.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30195.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31521.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28398.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26641.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13236.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28218.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "941", "type": "MS-DRG" } ], "description": "O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43248.4, "minimum": 16957.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43248.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38657.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40356.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36357.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34108.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16957.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36127.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1385.27, "90th_percentile": 1385.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1385.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "940", "type": "MS-DRG" } ], "description": "O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 46725.18, "minimum": 19358.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46725.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41765.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43600.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39280.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36850.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19358.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39031.6 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16919.31, "90th_percentile": 16919.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16919.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 41767.71, "90th_percentile": 41767.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41767.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44173.2, "90th_percentile": 44173.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44173.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15654.47, "90th_percentile": 15654.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15654.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "939", "type": "MS-DRG" } ], "description": "O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 70239.37, "minimum": 29388.85, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70239.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 62784.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 65542.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59048.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55395.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29388.85 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58674.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "935", "type": "MS-DRG" } ], "description": "Non-Extensive Burns", "standard_charges": [ { "billing_class": "facility", "maximum": 48606.32, "minimum": 17208.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48606.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 43447.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 45355.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40862.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38334.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17208.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40603.0 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32637.95, "90th_percentile": 32637.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32637.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "934", "type": "MS-DRG" } ], "description": "Full Thickness Burn Without Skin Graft Or Inhalation Injury", "standard_charges": [ { "billing_class": "facility", "maximum": 47486.49, "minimum": 18377.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47486.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42446.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44310.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39920.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37451.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18377.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39667.56 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "933", "type": "MS-DRG" } ], "description": "Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft", "standard_charges": [ { "billing_class": "facility", "maximum": 95754.2, "minimum": 31452.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 95754.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 85590.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 89350.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 80498.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75518.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31452.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 79987.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "929", "type": "MS-DRG" } ], "description": "Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 70381.01, "minimum": 26222.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70381.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 62910.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 65674.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59167.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55507.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26222.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58792.36 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "928", "type": "MS-DRG" } ], "description": "Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 147801.88, "minimum": 56912.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 147801.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 132114.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 137917.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 124253.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 116566.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56912.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 123465.43 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "927", "type": "MS-DRG" } ], "description": "Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft", "standard_charges": [ { "billing_class": "facility", "maximum": 525009.29, "minimum": 167014.58, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 525009.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 469284.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 489899.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 441362.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 414057.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167014.58 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 438563.4 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "923", "type": "MS-DRG" } ], "description": "Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22569.19, "minimum": 9113.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22569.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20173.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21059.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18973.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17799.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9113.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18853.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "922", "type": "MS-DRG" } ], "description": "Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 37383.69, "minimum": 14796.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37383.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33415.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34883.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31427.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29483.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14796.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 31228.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13660.08, "90th_percentile": 13660.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13660.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 27536.84, "90th_percentile": 27536.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27536.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12617.01, "90th_percentile": 12617.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12617.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "921", "type": "MS-DRG" } ], "description": "Complications Of Treatment Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15217.28, "minimum": 6556.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15217.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13602.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14199.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12792.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12001.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6556.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12711.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 11929.06, "90th_percentile": 11929.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11929.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12506.2, "90th_percentile": 13604.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13507.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5155.57, "90th_percentile": 5155.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5155.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 5781.0, "90th_percentile": 5781.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5781.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6079.73, "90th_percentile": 6079.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6079.73, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2501.52, "90th_percentile": 3792.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2501.52, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 14201.69, "90th_percentile": 14201.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14201.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 4055.93, "90th_percentile": 4055.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4055.93, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6082.54, "90th_percentile": 6082.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6082.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4199.67, "90th_percentile": 4199.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4199.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6232.57, "90th_percentile": 6232.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6232.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6155.18, "90th_percentile": 6155.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6155.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5585.62, "90th_percentile": 12706.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12693.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "920", "type": "MS-DRG" } ], "description": "Complications Of Treatment With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22480.67, "minimum": 8994.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22480.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20094.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20977.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18898.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17729.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8994.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18779.09 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22461.55, "90th_percentile": 22461.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22461.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6899.74, "90th_percentile": 8587.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7828.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11635.15, "90th_percentile": 20899.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 20096.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7039.25, "90th_percentile": 8597.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8386.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 16592.91, "90th_percentile": 16592.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16592.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4599.91, "90th_percentile": 5382.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4599.91, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5949.27, "90th_percentile": 8228.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5949.27, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 22080.59, "90th_percentile": 22080.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22080.59, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6397.22, "90th_percentile": 8548.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 8197.89, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18900.82, "90th_percentile": 19930.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19930.94, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 17721.3, "90th_percentile": 17721.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17721.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8542.06, "90th_percentile": 8542.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8542.06, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9090.36, "90th_percentile": 9090.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9090.36, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7212.44, "90th_percentile": 7212.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7212.44, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18500.45, "90th_percentile": 18751.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18500.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13298.43, "90th_percentile": 13298.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13298.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6830.52, "90th_percentile": 8675.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 8238.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17731.52, "90th_percentile": 18751.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18751.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "919", "type": "MS-DRG" } ], "description": "Complications Of Treatment With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40353.67, "minimum": 15428.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40353.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36070.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37655.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33924.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31825.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15428.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33709.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 40319.8, "90th_percentile": 40319.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40319.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1292.62, "90th_percentile": 14675.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 13340.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9090.36, "90th_percentile": 9090.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9090.36, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20649.38, "90th_percentile": 38025.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27470.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12936.6, "90th_percentile": 14987.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14633.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 13144.84, "90th_percentile": 13144.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13144.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 17390.51, "90th_percentile": 17390.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17390.51, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8228.35, "90th_percentile": 8228.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8228.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12790.02, "90th_percentile": 14987.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14633.42, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29090.4, "90th_percentile": 37654.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35777.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 19934.36, "90th_percentile": 19934.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19934.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14958.7, "90th_percentile": 14958.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14958.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 14642.54, "90th_percentile": 14642.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14642.54, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15157.64, "90th_percentile": 15157.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15157.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14719.06, "90th_percentile": 14719.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14719.06, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 15429.65, "90th_percentile": 15429.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15429.65, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13165.19, "90th_percentile": 15124.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13361.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33792.91, "90th_percentile": 33792.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33792.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "918", "type": "MS-DRG" } ], "description": "Poisoning And Toxic Effects Of Drugs Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19572.66, "minimum": 7866.68, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19572.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17495.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18263.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16454.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15436.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7866.68 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16349.9 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8500.4, "90th_percentile": 8500.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8500.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7567.4, "90th_percentile": 7567.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7567.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5712.8, "90th_percentile": 5712.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5712.8, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12385.79, "90th_percentile": 29512.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17375.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 5994.27, "90th_percentile": 5994.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5994.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3788.26, "90th_percentile": 3788.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3788.26, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4001.17, "90th_percentile": 4269.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4083.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19166.59, "90th_percentile": 19166.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19166.59, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7201.42, "90th_percentile": 7201.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7201.42, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4420.34, "90th_percentile": 4625.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4420.34, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6279.86, "90th_percentile": 6279.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6279.86, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7405.96, "90th_percentile": 7405.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7405.96, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15439.81, "90th_percentile": 15439.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15439.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4191.7, "90th_percentile": 4191.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4191.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7004.21, "90th_percentile": 7004.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7004.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15820.35, "90th_percentile": 16327.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15820.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "917", "type": "MS-DRG" } ], "description": "Poisoning And Toxic Effects Of Drugs With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36285.99, "minimum": 13390.5, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36285.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32434.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33859.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30504.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28617.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13390.5 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30311.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 36253.77, "90th_percentile": 36253.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36253.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9001.17, "90th_percentile": 12272.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11354.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6012.87, "90th_percentile": 6012.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6012.87, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26777.4, "90th_percentile": 37701.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28947.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5666.94, "90th_percentile": 5666.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5666.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11214.83, "90th_percentile": 13246.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11698.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 42747.78, "90th_percentile": 42747.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42747.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4738.79, "90th_percentile": 4850.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4738.79, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4369.85, "90th_percentile": 4369.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4369.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4512.82, "90th_percentile": 9424.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 5360.62, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10672.99, "90th_percentile": 10672.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10672.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 49435.77, "90th_percentile": 49435.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49435.77, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 23490.6, "90th_percentile": 23490.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23490.6, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5788.05, "90th_percentile": 5788.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5788.05, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11045.47, "90th_percentile": 22436.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13007.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32169.27, "90th_percentile": 32169.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32169.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13277.9, "90th_percentile": 13277.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13277.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2951.99, "90th_percentile": 6012.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5392.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28619.32, "90th_percentile": 28619.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28619.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4386.4, "90th_percentile": 9872.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6819.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11605.29, "90th_percentile": 11656.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11605.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30265.58, "90th_percentile": 30265.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30265.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "916", "type": "MS-DRG" } ], "description": "Allergic Reactions Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14694.98, "minimum": 6384.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14694.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13135.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13712.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12353.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11589.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6384.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12275.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5896.79, "90th_percentile": 5896.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5896.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12896.82, "90th_percentile": 13847.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12896.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5904.99, "90th_percentile": 5904.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5904.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10036.73, "90th_percentile": 10036.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10036.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12257.96, "90th_percentile": 12257.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12257.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "915", "type": "MS-DRG" } ], "description": "Allergic Reactions With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 38459.25, "minimum": 14269.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38459.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 34377.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 35887.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32331.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30331.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14269.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32126.71 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11147.31, "90th_percentile": 11147.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11147.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31174.05, "90th_percentile": 31174.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31174.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3443.92, "90th_percentile": 3443.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3443.92, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7591.77, "90th_percentile": 7591.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7591.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13987.11, "90th_percentile": 13987.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13987.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7591.77, "90th_percentile": 7591.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7591.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12556.47, "90th_percentile": 12556.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12556.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30333.31, "90th_percentile": 30333.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30333.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "914", "type": "MS-DRG" } ], "description": "Traumatic Injury Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20278.64, "minimum": 8087.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20278.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18126.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18922.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17047.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15993.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8087.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16939.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 63804.44, "90th_percentile": 63804.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63804.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7487.86, "90th_percentile": 7487.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7487.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "913", "type": "MS-DRG" } ], "description": "Traumatic Injury With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35812.38, "minimum": 13904.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35812.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32011.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33417.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30106.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28244.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13904.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29915.66 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "909", "type": "MS-DRG" } ], "description": "Other O.R. Procedures For Injuries Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28066.53, "minimum": 11404.78, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28066.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25087.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26189.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23594.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22135.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11404.78 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23445.21 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30692.24, "90th_percentile": 32934.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30692.24, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10454.74, "90th_percentile": 10454.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10454.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25089.51, "90th_percentile": 25089.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25089.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10877.3, "90th_percentile": 10877.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10877.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7138.55, "90th_percentile": 7138.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7138.55, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10618.49, "90th_percentile": 10618.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10618.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10441.14, "90th_percentile": 10441.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10441.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24229.82, "90th_percentile": 25581.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24229.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "908", "type": "MS-DRG" } ], "description": "Other O.R. Procedures For Injuries With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 44638.23, "minimum": 16704.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44638.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39900.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41653.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37526.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35204.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16704.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37288.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 48289.4, "90th_percentile": 48289.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48289.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1429.78, "90th_percentile": 16116.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14680.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44066.07, "90th_percentile": 44066.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44066.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39619.88, "90th_percentile": 42060.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39902.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 16879.87, "90th_percentile": 16879.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16879.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12601.35, "90th_percentile": 16228.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15316.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 20944.3, "90th_percentile": 20944.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20944.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10879.13, "90th_percentile": 15967.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10879.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 15201.9, "90th_percentile": 15201.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15201.9, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13941.3, "90th_percentile": 16136.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15326.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12109.52, "90th_percentile": 12109.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12109.52, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37290.13, "90th_percentile": 37290.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37290.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 15571.23, "90th_percentile": 15571.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15571.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14321.31, "90th_percentile": 14493.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14321.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 37794.19, "90th_percentile": 37794.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37794.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "907", "type": "MS-DRG" } ], "description": "Other O.R. Procedures For Injuries With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 88158.84, "minimum": 31025.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88158.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 78801.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 82263.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 74113.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 69528.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31025.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 73642.96 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2823.76, "90th_percentile": 28105.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2823.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 78805.55, "90th_percentile": 448856.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78805.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30924.11, "90th_percentile": 31014.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30924.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 60607.42, "90th_percentile": 60607.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60607.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 23556.5, "90th_percentile": 23556.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23556.5, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 26322.51, "90th_percentile": 26322.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26322.51, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 61000.85, "90th_percentile": 61000.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61000.85, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 28719.42, "90th_percentile": 28719.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28719.42, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25139.52, "90th_percentile": 30924.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28762.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 785183.08, "90th_percentile": 785183.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 785183.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 22650.12, "90th_percentile": 32874.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28152.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32027.43, "90th_percentile": 32027.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32027.43, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12309.39, "90th_percentile": 12309.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12309.39, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 73531.13, "90th_percentile": 76264.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73531.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28364.56, "90th_percentile": 36114.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29964.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 73531.13, "90th_percentile": 73531.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73531.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "906", "type": "MS-DRG" } ], "description": "Hand Procedures For Injuries", "standard_charges": [ { "billing_class": "facility", "maximum": 48298.69, "minimum": 16464.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48298.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 43172.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 45068.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40603.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38091.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16464.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40346.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42868.67, "90th_percentile": 43174.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42868.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8226.55, "90th_percentile": 8226.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8226.55, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "905", "type": "MS-DRG" } ], "description": "Skin Grafts For Injuries Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36474.1, "minimum": 12730.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36474.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32602.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34034.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30662.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28765.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12730.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30468.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "904", "type": "MS-DRG" } ], "description": "Skin Grafts For Injuries With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 85445.58, "minimum": 29735.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85445.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 76376.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 79731.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 71832.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 67388.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29735.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 71376.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 75750.92, "90th_percentile": 75750.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75750.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 208543.43, "90th_percentile": 208543.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 208543.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "903", "type": "MS-DRG" } ], "description": "Wound Debridements For Injuries Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 26977.69, "minimum": 10293.49, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26977.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24114.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25173.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22679.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21276.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10293.49 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22535.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19522.39, "90th_percentile": 19522.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19522.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "902", "type": "MS-DRG" } ], "description": "Wound Debridements For Injuries With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 41991.36, "minimum": 16078.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41991.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37534.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39183.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35301.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33117.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16078.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 35077.23 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15198.9, "90th_percentile": 15198.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15198.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14878.33, "90th_percentile": 14878.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14878.33, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13062.53, "90th_percentile": 13062.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13062.53, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 15191.51, "90th_percentile": 15191.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15191.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39199.99, "90th_percentile": 39199.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39199.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "901", "type": "MS-DRG" } ], "description": "Wound Debridements For Injuries With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 98044.76, "minimum": 33800.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 98044.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 87638.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 91488.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82423.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77324.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33800.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 81901.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31153.42, "90th_percentile": 31153.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31153.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32651.22, "90th_percentile": 32651.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32651.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 32776.31, "90th_percentile": 32776.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32776.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24397.8, "90th_percentile": 24397.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24397.8, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 81778.17, "90th_percentile": 81778.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 81778.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "897", "type": "MS-DRG" } ], "description": "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19523.97, "minimum": 8066.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19523.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17451.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18218.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16413.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15397.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8066.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16309.23 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8829.0, "90th_percentile": 20601.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8829.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "10th_percentile": 5716.04, "90th_percentile": 5716.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5716.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7542.92, "90th_percentile": 7597.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7542.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 7799.67, "90th_percentile": 8232.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7843.59, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6630.61, "90th_percentile": 6978.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 6630.61, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2273.52, "90th_percentile": 11382.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 5718.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5169.87, "90th_percentile": 8599.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6344.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6622.34, "90th_percentile": 6622.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6622.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4545.33, "90th_percentile": 19917.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6083.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5430.24, "90th_percentile": 7285.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5504.49, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9072.0, "90th_percentile": 9072.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9072.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4805.17, "90th_percentile": 6235.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 6001.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19174.62, "90th_percentile": 19174.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19174.62, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 5520.38, "90th_percentile": 5520.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5520.38, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6630.61, "90th_percentile": 9883.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 6630.61, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5483.2, "90th_percentile": 7558.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 6677.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10188.0, "90th_percentile": 11875.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10188.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4049.44, "90th_percentile": 6630.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5493.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6251.36, "90th_percentile": 7807.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6366.55, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5689.04, "90th_percentile": 5689.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5689.04, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13251.33, "90th_percentile": 14294.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13251.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4750.21, "90th_percentile": 9371.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 4948.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5795.38, "90th_percentile": 7907.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6251.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5967.0, "90th_percentile": 16294.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15397.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "896", "type": "MS-DRG" } ], "description": "Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 39410.88, "minimum": 14762.72, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39410.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35227.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36775.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33131.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31082.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14762.72 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32921.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12312.99, "90th_percentile": 14301.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13992.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6224.0, "90th_percentile": 6224.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6224.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 1311.78, "90th_percentile": 1311.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1311.78, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6721.27, "90th_percentile": 19695.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9973.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14296.0, "90th_percentile": 82202.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18970.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9457.03, "90th_percentile": 14157.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9457.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11405.96, "90th_percentile": 14339.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11405.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 25223.03, "90th_percentile": 25223.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25223.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7036.72, "90th_percentile": 14003.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8093.86, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6001.84, "90th_percentile": 9027.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 8911.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 25369.1, "90th_percentile": 25369.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25369.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8592.2, "90th_percentile": 9883.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8895.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11003.12, "90th_percentile": 14319.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13409.05, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40752.0, "90th_percentile": 63224.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40752.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 13418.92, "90th_percentile": 13418.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13418.92, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6888.28, "90th_percentile": 19695.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9883.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14866.11, "90th_percentile": 14866.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14866.11, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 100456.97, "90th_percentile": 100456.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 100456.97, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6287.64, "90th_percentile": 18677.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8435.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12766.46, "90th_percentile": 14441.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13265.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31089.89, "90th_percentile": 31089.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31089.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "895", "type": "MS-DRG" } ], "description": "Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 32043.47, "minimum": 12203.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32043.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28642.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29900.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26938.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25271.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12203.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26767.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "894", "type": "MS-DRG" } ], "description": "Alcohol, Drug Abuse Or Dependence, Left Ama", "standard_charges": [ { "billing_class": "facility", "maximum": 13811.96, "minimum": 6001.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13811.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12345.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 12888.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11611.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 10893.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6001.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11537.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4617.35, "90th_percentile": 4617.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4617.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7148.0, "90th_percentile": 7148.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7148.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3376.61, "90th_percentile": 4418.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3376.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4432.5, "90th_percentile": 4432.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4432.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4370.59, "90th_percentile": 4370.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4370.59, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6609.75, "90th_percentile": 12896.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6609.75, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7302.2, "90th_percentile": 7302.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7302.2, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10893.04, "90th_percentile": 10893.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10893.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4292.54, "90th_percentile": 4292.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4292.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "887", "type": "MS-DRG" } ], "description": "Other Mental Disorder Diagnoses", "standard_charges": [ { "billing_class": "facility", "maximum": 26320.4, "minimum": 9527.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26320.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23526.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24560.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22126.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20758.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9527.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21986.59 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 843.08, "90th_percentile": 843.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 843.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21953.95, "90th_percentile": 21953.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21953.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "886", "type": "MS-DRG" } ], "description": "Behavioral And Developmental Disorders", "standard_charges": [ { "billing_class": "facility", "maximum": 39756.13, "minimum": 17326.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39756.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35536.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37097.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33422.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31354.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17326.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33210.05 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6001.19, "90th_percentile": 6001.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6001.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "885", "type": "MS-DRG" } ], "description": "Psychoses", "standard_charges": [ { "billing_class": "facility", "maximum": 31193.64, "minimum": 12057.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31193.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27882.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29107.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26223.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24601.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12057.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26057.43 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5633.67, "90th_percentile": 52875.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 11772.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "10th_percentile": 5068.68, "90th_percentile": 8433.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 5725.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3029.63, "90th_percentile": 29345.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 10285.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17658.0, "90th_percentile": 17658.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17658.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 6526.93, "90th_percentile": 6526.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6526.93, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4614.14, "90th_percentile": 11058.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 9692.43, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6608.85, "90th_percentile": 46462.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "74", "median_amount": 14296.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4739.61, "90th_percentile": 14583.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 8372.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3945.43, "90th_percentile": 30755.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 9863.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8589.05, "90th_percentile": 125778.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8589.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4189.64, "90th_percentile": 15057.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8356.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4305.49, "90th_percentile": 9533.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 8355.54, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12713.7, "90th_percentile": 12713.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12713.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4597.54, "90th_percentile": 10009.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "97", "median_amount": 8773.32, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20945.99, "90th_percentile": 20945.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20945.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9952.71, "90th_percentile": 31805.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13959.46, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 10722.61, "90th_percentile": 29885.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13847.76, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6304.79, "90th_percentile": 55586.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6304.79, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 7592.45, "90th_percentile": 19822.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9781.84, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5879.67, "90th_percentile": 15240.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 7002.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2273.16, "90th_percentile": 19188.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "62", "median_amount": 7787.36, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8141.58, "90th_percentile": 58244.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 20171.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 5257.21, "90th_percentile": 8945.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5795.42, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 6500.56, "90th_percentile": 16343.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11517.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 999.26, "90th_percentile": 999.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 999.26, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4664.42, "90th_percentile": 15240.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "55", "median_amount": 9692.43, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2608.02, "90th_percentile": 23380.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 5128.24, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8445.24, "90th_percentile": 8445.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8445.24, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6516.37, "90th_percentile": 38649.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 9082.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5879.67, "90th_percentile": 10486.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 9692.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5145.89, "90th_percentile": 14344.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 9180.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4919.55, "90th_percentile": 24899.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 11456.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "884", "type": "MS-DRG" } ], "description": "Organic Disturbances And Intellectual Disability", "standard_charges": [ { "billing_class": "facility", "maximum": 36960.98, "minimum": 13705.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36960.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33037.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34489.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31072.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29149.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13705.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30875.14 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10685.09, "90th_percentile": 13522.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 12293.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14296.0, "90th_percentile": 14296.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14296.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1150.99, "90th_percentile": 53158.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12311.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3755.11, "90th_percentile": 3755.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3755.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13598.77, "90th_percentile": 13598.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13598.77, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7022.31, "90th_percentile": 12450.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 10530.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18345.34, "90th_percentile": 18345.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18345.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8708.12, "90th_percentile": 8708.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8708.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8929.9, "90th_percentile": 20925.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10694.76, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13557.52, "90th_percentile": 13557.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13557.52, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12320.1, "90th_percentile": 12320.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12320.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8549.59, "90th_percentile": 8549.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8549.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12418.1, "90th_percentile": 13599.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12871.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "883", "type": "MS-DRG" } ], "description": "Disorders Of Personality And Impulse Control", "standard_charges": [ { "billing_class": "facility", "maximum": 41083.99, "minimum": 16480.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41083.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36723.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38336.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34538.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32401.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16480.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34319.27 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "10th_percentile": 7081.98, "90th_percentile": 7081.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7081.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7081.98, "90th_percentile": 7081.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7081.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4906.1, "90th_percentile": 4906.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4906.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8534.1, "90th_percentile": 8534.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8534.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "882", "type": "MS-DRG" } ], "description": "Neuroses Except Depressive", "standard_charges": [ { "billing_class": "facility", "maximum": 21287.81, "minimum": 9549.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21287.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19028.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19864.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17896.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16789.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9549.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17782.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 4414.5, "90th_percentile": 4414.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4414.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "10th_percentile": 5926.19, "90th_percentile": 7502.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5926.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17751.25, "90th_percentile": 17751.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17751.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8703.45, "90th_percentile": 8703.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8703.45, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2998.45, "90th_percentile": 11107.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5486.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6429.34, "90th_percentile": 6429.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6429.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2487.47, "90th_percentile": 2487.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2487.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6081.81, "90th_percentile": 7045.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6557.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 8663.87, "90th_percentile": 8663.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8663.87, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8703.45, "90th_percentile": 11762.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8703.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6860.48, "90th_percentile": 6860.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6860.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6792.0, "90th_percentile": 6792.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6792.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9615.93, "90th_percentile": 9615.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9615.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7783.18, "90th_percentile": 7783.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7783.18, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2474.07, "90th_percentile": 2474.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2474.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6624.69, "90th_percentile": 6624.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6624.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11654.59, "90th_percentile": 11654.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11654.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7502.97, "90th_percentile": 9448.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7502.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9456.09, "90th_percentile": 9456.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9456.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "881", "type": "MS-DRG" } ], "description": "Depressive Neuroses", "standard_charges": [ { "billing_class": "facility", "maximum": 20229.95, "minimum": 8517.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20229.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18082.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18877.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17006.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15954.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8517.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16898.97 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "10th_percentile": 5646.93, "90th_percentile": 5646.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5646.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3776.89, "90th_percentile": 3776.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3776.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3794.0, "90th_percentile": 15176.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 7101.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5725.09, "90th_percentile": 5725.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5725.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8860.72, "90th_percentile": 8860.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8860.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5725.09, "90th_percentile": 5725.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5725.09, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3772.53, "90th_percentile": 9247.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5345.3, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4744.56, "90th_percentile": 4744.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4744.56, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 5239.57, "90th_percentile": 5239.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5239.57, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7795.14, "90th_percentile": 7795.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7795.14, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10188.0, "90th_percentile": 13046.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10188.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4991.19, "90th_percentile": 4991.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4991.19, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5368.57, "90th_percentile": 12276.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8666.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5970.33, "90th_percentile": 10215.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5970.33, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5754.53, "90th_percentile": 5754.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5754.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7867.77, "90th_percentile": 7867.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7867.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "880", "type": "MS-DRG" } ], "description": "Acute Adjustment Reaction And Psychosocial Dysfunction", "standard_charges": [ { "billing_class": "facility", "maximum": 21214.78, "minimum": 8667.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21214.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18963.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19796.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17834.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16731.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8667.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17721.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 6871.34, "90th_percentile": 27745.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17851.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6423.82, "90th_percentile": 8419.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8110.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11772.0, "90th_percentile": 11772.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11772.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7744.52, "90th_percentile": 7744.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7744.52, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3574.0, "90th_percentile": 22764.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10722.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6578.07, "90th_percentile": 10043.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6578.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7551.33, "90th_percentile": 7840.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7551.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3574.0, "90th_percentile": 3574.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3574.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 16386.02, "90th_percentile": 16386.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16386.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2925.06, "90th_percentile": 2925.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2925.06, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21673.89, "90th_percentile": 21673.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21673.89, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5020.89, "90th_percentile": 7977.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 6222.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 48734.14, "90th_percentile": 48734.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48734.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7783.18, "90th_percentile": 7783.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7783.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8109.93, "90th_percentile": 8497.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8109.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16980.0, "90th_percentile": 16980.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16980.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 9597.28, "90th_percentile": 9597.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9597.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 4055.26, "90th_percentile": 4055.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4055.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6172.86, "90th_percentile": 7783.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6965.05, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8428.87, "90th_percentile": 8428.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8428.87, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17693.84, "90th_percentile": 17693.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17693.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4601.2, "90th_percentile": 7783.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6874.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6710.89, "90th_percentile": 46912.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6744.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16731.4, "90th_percentile": 149269.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17693.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "876", "type": "MS-DRG" } ], "description": "O.R. Procedures With Principal Diagnosis Of Mental Illness", "standard_charges": [ { "billing_class": "facility", "maximum": 86961.55, "minimum": 31224.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 86961.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 77731.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 81146.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 73106.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68583.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31224.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 72642.82 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7895.15, "90th_percentile": 7895.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7895.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23737.23, "90th_percentile": 23737.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23737.23, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 20732.17, "90th_percentile": 20732.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20732.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "872", "type": "MS-DRG" } ], "description": "Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22817.06, "minimum": 9157.36, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22817.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20395.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21291.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19181.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17995.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9157.36 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19060.1 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18093.9, "90th_percentile": 28768.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 21575.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5965.75, "90th_percentile": 8671.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 7886.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 6764.58, "90th_percentile": 8996.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7605.34, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15594.21, "90th_percentile": 20395.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 20250.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4557.78, "90th_percentile": 8590.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5609.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6433.33, "90th_percentile": 8687.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 8144.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 13673.35, "90th_percentile": 16315.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13673.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4855.45, "90th_percentile": 4855.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4855.45, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5366.55, "90th_percentile": 5448.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 5366.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8731.57, "90th_percentile": 8731.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8731.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 29639.42, "90th_percentile": 29639.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29639.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 8817.85, "90th_percentile": 8817.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8817.85, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5928.76, "90th_percentile": 5928.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5928.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7086.2, "90th_percentile": 8977.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 8679.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14951.9, "90th_percentile": 20227.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 18305.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8876.53, "90th_percentile": 8876.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8876.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 9049.2, "90th_percentile": 9049.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9049.2, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4295.82, "90th_percentile": 12053.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5928.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8967.59, "90th_percentile": 8967.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8967.59, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12727.38, "90th_percentile": 12727.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12727.38, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16228.0, "90th_percentile": 19030.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17995.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5622.1, "90th_percentile": 5708.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5622.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6820.72, "90th_percentile": 8735.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 7177.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17197.57, "90th_percentile": 19030.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 18888.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "871", "type": "MS-DRG" } ], "description": "Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43427.66, "minimum": 16295.69, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43427.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38818.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40523.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36508.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34249.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16295.69 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36277.04 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 25979.8, "90th_percentile": 160013.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 42893.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10181.14, "90th_percentile": 15722.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "230", "median_amount": 14292.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 14191.64, "90th_percentile": 21104.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16103.35, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6019.43, "90th_percentile": 17452.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 16272.25, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19860.0, "90th_percentile": 40505.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "81", "median_amount": 38539.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5498.19, "90th_percentile": 16700.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 8677.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12160.57, "90th_percentile": 15756.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "144", "median_amount": 14312.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 7621.52, "90th_percentile": 75240.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 20652.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4894.17, "90th_percentile": 14293.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 7426.5, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13727.99, "90th_percentile": 13727.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13727.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5118.92, "90th_percentile": 15797.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 8208.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40519.33, "90th_percentile": 134056.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75461.44, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 21867.5, "90th_percentile": 116259.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 37436.36, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 12798.85, "90th_percentile": 16046.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15619.72, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8977.48, "90th_percentile": 17452.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 17452.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12299.49, "90th_percentile": 15784.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "201", "median_amount": 14287.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 25851.96, "90th_percentile": 226497.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 38109.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 34296.87, "90th_percentile": 34296.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34296.87, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 1389.65, "90th_percentile": 15976.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 15678.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 1390.8, "90th_percentile": 17147.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 15484.96, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5655.19, "90th_percentile": 17543.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 8977.48, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9792.04, "90th_percentile": 16242.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 14851.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32597.21, "90th_percentile": 32597.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32597.21, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 1390.8, "90th_percentile": 1390.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1390.8, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31149.78, "90th_percentile": 36216.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 34246.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5622.1, "90th_percentile": 16636.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 16550.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9855.92, "90th_percentile": 15865.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "146", "median_amount": 14510.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32772.1, "90th_percentile": 36216.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 35854.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "870", "type": "MS-DRG" } ], "description": "Septicemia Or Severe Sepsis With Mv >96 Hours", "standard_charges": [ { "billing_class": "facility", "maximum": 153954.3, "minimum": 54886.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 153954.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 137613.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 143658.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 129425.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 121418.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54886.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 128604.82 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 153499.53, "90th_percentile": 153499.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 153499.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39056.71, "90th_percentile": 53356.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 48413.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 53580.09, "90th_percentile": 53580.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53580.09, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17452.9, "90th_percentile": 17543.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17452.9, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 219221.6, "90th_percentile": 427676.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 257490.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48412.89, "90th_percentile": 63558.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53343.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 76079.26, "90th_percentile": 105954.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84099.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 15797.88, "90th_percentile": 30528.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 15797.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 475578.32, "90th_percentile": 475578.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 475578.32, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 17452.9, "90th_percentile": 17452.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17452.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50732.47, "90th_percentile": 53502.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 51670.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 48378.05, "90th_percentile": 48378.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48378.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17452.9, "90th_percentile": 17452.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17452.9, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47771.85, "90th_percentile": 47771.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47771.85, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 219909.86, "90th_percentile": 219909.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 219909.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 16550.16, "90th_percentile": 28598.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16550.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48897.03, "90th_percentile": 57723.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 52652.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 201530.14, "90th_percentile": 687312.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 357356.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "869", "type": "MS-DRG" } ], "description": "Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 15923.25, "minimum": 6877.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15923.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14233.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14858.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13386.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12558.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6877.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13301.4 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13250.25, "90th_percentile": 13250.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13250.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5243.34, "90th_percentile": 5243.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5243.34, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "868", "type": "MS-DRG" } ], "description": "Other Infectious And Parasitic Diseases Diagnoses With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23237.55, "minimum": 9217.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23237.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20771.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21683.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19535.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18326.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9217.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19411.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 21707.89, "90th_percentile": 21707.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21707.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 11429.76, "90th_percentile": 11429.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11429.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18328.45, "90th_percentile": 18328.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18328.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "867", "type": "MS-DRG" } ], "description": "Other Infectious And Parasitic Diseases Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 47453.29, "minimum": 17466.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47453.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42416.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44279.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39892.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37424.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17466.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39639.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17075.55, "90th_percentile": 17075.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17075.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "866", "type": "MS-DRG" } ], "description": "Viral Illness Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19579.3, "minimum": 7963.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19579.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17501.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18269.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16459.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15441.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7963.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16355.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5956.58, "90th_percentile": 5956.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5956.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17503.11, "90th_percentile": 17503.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17503.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6514.05, "90th_percentile": 6514.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6514.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4129.92, "90th_percentile": 4129.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4129.92, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19231.13, "90th_percentile": 19231.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19231.13, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17358.89, "90th_percentile": 17358.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17358.89, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 7631.29, "90th_percentile": 7631.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7631.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22048.61, "90th_percentile": 22048.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22048.61, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13523.36, "90th_percentile": 13523.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13523.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "865", "type": "MS-DRG" } ], "description": "Viral Illness With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32663.14, "minimum": 12846.12, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32663.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29196.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30478.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27459.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25760.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12846.12 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27284.96 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12044.9, "90th_percentile": 12044.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12044.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22129.45, "90th_percentile": 22129.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22129.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28989.63, "90th_percentile": 28989.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28989.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12594.36, "90th_percentile": 12594.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12594.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 12397.04, "90th_percentile": 12397.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12397.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 31931.3, "90th_percentile": 31931.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31931.3, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11102.18, "90th_percentile": 11102.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11102.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 11633.73, "90th_percentile": 11633.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11633.73, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "864", "type": "MS-DRG" } ], "description": "Fever And Inflammatory Conditions", "standard_charges": [ { "billing_class": "facility", "maximum": 19871.42, "minimum": 8104.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19871.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17762.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18542.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16705.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15671.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8104.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16599.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20755.31, "90th_percentile": 20755.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20755.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7031.95, "90th_percentile": 7031.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7031.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17638.52, "90th_percentile": 17638.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17638.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7796.09, "90th_percentile": 7796.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7796.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4279.58, "90th_percentile": 4279.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4279.58, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 20733.69, "90th_percentile": 20733.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20733.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7649.77, "90th_percentile": 7649.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7649.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13136.93, "90th_percentile": 13136.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13136.93, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7723.07, "90th_percentile": 7723.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7723.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16575.28, "90th_percentile": 16575.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16575.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "863", "type": "MS-DRG" } ], "description": "Postoperative And Post-Traumatic Infections Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22128.79, "minimum": 8960.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22128.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19780.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20648.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18603.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17452.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8960.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18485.15 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15823.82, "90th_percentile": 15823.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15823.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7715.61, "90th_percentile": 8703.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8052.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7140.91, "90th_percentile": 7140.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7140.91, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15877.55, "90th_percentile": 20558.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20558.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8421.38, "90th_percentile": 8475.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8421.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 17430.5, "90th_percentile": 17430.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17430.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5389.5, "90th_percentile": 17586.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6463.76, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7050.25, "90th_percentile": 11128.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7050.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7874.75, "90th_percentile": 8784.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8070.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19617.04, "90th_percentile": 19617.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19617.04, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 8421.39, "90th_percentile": 8421.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8421.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7050.25, "90th_percentile": 11128.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7050.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7083.9, "90th_percentile": 7083.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7083.9, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 713.89, "90th_percentile": 713.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 713.89, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18456.15, "90th_percentile": 18456.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18456.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6290.93, "90th_percentile": 6290.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6290.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8462.15, "90th_percentile": 13664.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8462.15, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17452.25, "90th_percentile": 18456.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17452.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "862", "type": "MS-DRG" } ], "description": "Postoperative And Post-Traumatic Infections With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40690.06, "minimum": 15373.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40690.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36371.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37968.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34207.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32090.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15373.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33990.2 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 25587.52, "90th_percentile": 41111.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37981.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1354.43, "90th_percentile": 14759.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 13444.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23869.75, "90th_percentile": 38027.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 36115.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10648.37, "90th_percentile": 10648.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10648.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14065.05, "90th_percentile": 14846.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14160.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6381.69, "90th_percentile": 10072.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6463.76, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 70422.13, "90th_percentile": 70422.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 70422.13, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11128.03, "90th_percentile": 11128.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11128.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14747.3, "90th_percentile": 14803.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14747.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34209.01, "90th_percentile": 36073.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35517.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14773.7, "90th_percentile": 14773.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14773.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7140.91, "90th_percentile": 20681.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7140.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 17890.62, "90th_percentile": 19611.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17890.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14883.34, "90th_percentile": 16776.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15070.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32092.67, "90th_percentile": 33938.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32092.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "858", "type": "MS-DRG" } ], "description": "Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28513.58, "minimum": 12027.6, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28513.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25487.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26606.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23970.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22487.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12027.6 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23818.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8632.66, "90th_percentile": 8632.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8632.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "857", "type": "MS-DRG" } ], "description": "Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 48221.24, "minimum": 17841.09, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48221.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 43103.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44996.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40538.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38030.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17841.09 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40281.32 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 2088.31, "90th_percentile": 2088.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2088.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1544.47, "90th_percentile": 17339.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1605.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8890.77, "90th_percentile": 8890.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8890.77, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42797.95, "90th_percentile": 45434.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44119.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8507.55, "90th_percentile": 8507.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8507.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15783.13, "90th_percentile": 17362.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15783.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10486.7, "90th_percentile": 10486.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10486.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 50022.32, "90th_percentile": 50022.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50022.32, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11585.3, "90th_percentile": 11585.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11585.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11969.96, "90th_percentile": 17362.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16596.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42747.84, "90th_percentile": 42747.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42747.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 108923.79, "90th_percentile": 108923.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108923.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11585.3, "90th_percentile": 11585.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11585.3, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15552.48, "90th_percentile": 17489.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16034.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40218.14, "90th_percentile": 40218.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40218.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "856", "type": "MS-DRG" } ], "description": "Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 99839.58, "minimum": 36534.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 99839.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 89242.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 93162.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83932.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 78740.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36534.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 83400.4 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 63747.65, "90th_percentile": 63747.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63747.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2132.92, "90th_percentile": 35116.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32676.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 93712.32, "90th_percentile": 520074.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 93712.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32763.95, "90th_percentile": 34905.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33990.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 17586.04, "90th_percentile": 17586.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17586.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34162.95, "90th_percentile": 35008.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34882.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 90423.06, "90th_percentile": 90423.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90423.06, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 81045.53, "90th_percentile": 81045.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 81045.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 34905.35, "90th_percentile": 34905.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34905.35, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17362.8, "90th_percentile": 37471.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19428.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10552.44, "90th_percentile": 19525.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10552.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34963.02, "90th_percentile": 35222.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35222.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 85266.11, "90th_percentile": 85266.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85266.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "855", "type": "MS-DRG" } ], "description": "Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35973.94, "minimum": 12837.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35973.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32155.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33568.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30242.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28371.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12837.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30050.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30845.31, "90th_percentile": 30845.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30845.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3975.06, "90th_percentile": 3975.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3975.06, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "854", "type": "MS-DRG" } ], "description": "Infectious And Parasitic Diseases With O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 44222.16, "minimum": 16727.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44222.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 39528.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41264.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37176.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34876.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16727.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36940.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 35059.42, "90th_percentile": 44219.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37674.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8761.21, "90th_percentile": 16018.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15294.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6272.93, "90th_percentile": 6272.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6272.93, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35925.98, "90th_percentile": 39526.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 39009.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 9589.31, "90th_percentile": 9589.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9589.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14300.14, "90th_percentile": 16405.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14607.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8281.32, "90th_percentile": 8281.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8281.32, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35155.29, "90th_percentile": 35155.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35155.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5366.55, "90th_percentile": 9153.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5678.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 128930.0, "90th_percentile": 130203.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 128930.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15391.41, "90th_percentile": 15995.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15965.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35201.79, "90th_percentile": 45778.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39200.72, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14260.55, "90th_percentile": 14260.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14260.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14856.84, "90th_percentile": 14856.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14856.84, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 154995.83, "90th_percentile": 154995.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 154995.83, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 34874.84, "90th_percentile": 36880.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34874.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 15846.47, "90th_percentile": 15846.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15846.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11103.68, "90th_percentile": 18371.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14624.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30170.09, "90th_percentile": 166664.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35082.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "853", "type": "MS-DRG" } ], "description": "Infectious And Parasitic Diseases With O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 110688.2, "minimum": 39562.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110688.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 98939.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 103285.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93052.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87296.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39562.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92462.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 54663.52, "90th_percentile": 158378.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110428.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19306.72, "90th_percentile": 38603.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 35092.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 85295.4, "90th_percentile": 85295.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85295.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 31601.84, "90th_percentile": 31601.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31601.84, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38393.16, "90th_percentile": 38393.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38393.16, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69640.15, "90th_percentile": 562456.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 98932.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 36738.28, "90th_percentile": 36738.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36738.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30937.13, "90th_percentile": 51780.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 37050.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 65358.41, "90th_percentile": 65358.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65358.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 13611.33, "90th_percentile": 31442.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13611.33, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 9070.97, "90th_percentile": 29562.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 15044.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 61458.23, "90th_percentile": 198831.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90221.6, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 40619.54, "90th_percentile": 40619.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40619.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 33489.89, "90th_percentile": 37189.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35614.89, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 16620.16, "90th_percentile": 38393.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17452.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30187.4, "90th_percentile": 38834.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 36867.85, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 81644.48, "90th_percentile": 630894.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 282479.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 29976.35, "90th_percentile": 93794.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29976.35, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 3940.07, "90th_percentile": 65530.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38572.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 19237.02, "90th_percentile": 43436.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38614.56, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16620.16, "90th_percentile": 38393.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 20596.79, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36429.7, "90th_percentile": 38514.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37778.63, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 91156.68, "90th_percentile": 159283.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 92314.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 23344.33, "90th_percentile": 36407.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33418.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34816.07, "90th_percentile": 38979.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 37194.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 85448.14, "90th_percentile": 355039.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 92314.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "850", "type": "MS-DRG" } ], "description": "Acute Leukemia With Other Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 203855.28, "minimum": 68458.65, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 203855.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 182217.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 190222.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 171376.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 160774.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68458.65 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 170289.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24836.26, "90th_percentile": 24836.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24836.26, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63823.6, "90th_percentile": 63823.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63823.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 73901.38, "90th_percentile": 73901.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73901.38, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69521.5, "90th_percentile": 69521.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69521.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "849", "type": "MS-DRG" } ], "description": "Radiotherapy", "standard_charges": [ { "billing_class": "facility", "maximum": 59109.69, "minimum": 22252.07, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59109.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 52835.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 55156.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49692.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46617.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22252.07 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 49376.93 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "848", "type": "MS-DRG" } ], "description": "Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18123.08, "minimum": 7806.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18123.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16199.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16911.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15235.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14293.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7806.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15139.0 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4027.7, "90th_percentile": 7066.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6969.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7306.5, "90th_percentile": 7306.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7306.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "847", "type": "MS-DRG" } ], "description": "Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 28119.65, "minimum": 11369.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28119.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25135.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26239.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23639.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22177.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11369.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23489.58 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9707.31, "90th_percentile": 10839.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9707.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10564.29, "90th_percentile": 17633.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10564.29, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12157.2, "90th_percentile": 66481.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 24959.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 53654.81, "90th_percentile": 53654.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53654.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5733.22, "90th_percentile": 9480.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5733.22, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8793.24, "90th_percentile": 11044.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 10463.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7035.95, "90th_percentile": 24929.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7444.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 8659.55, "90th_percentile": 8793.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8681.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22178.8, "90th_percentile": 22178.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22178.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10017.87, "90th_percentile": 14252.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10017.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10363.3, "90th_percentile": 11248.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10559.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22178.8, "90th_percentile": 23454.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23454.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "846", "type": "MS-DRG" } ], "description": "Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 56513.72, "minimum": 21343.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56513.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50515.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 52734.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47509.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44570.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21343.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47208.4 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20198.65, "90th_percentile": 20198.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20198.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 27485.09, "90th_percentile": 27485.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27485.09, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12648.3, "90th_percentile": 53410.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50519.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20140.47, "90th_percentile": 20734.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20140.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 18097.72, "90th_percentile": 18097.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18097.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20218.38, "90th_percentile": 32377.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20925.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39545.9, "90th_percentile": 46295.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39860.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 233736.52, "90th_percentile": 233736.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 233736.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9931.89, "90th_percentile": 9931.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9931.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 155065.47, "90th_percentile": 155065.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 155065.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "845", "type": "MS-DRG" } ], "description": "Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18517.01, "minimum": 7823.97, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18517.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16551.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 17278.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15566.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14603.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7823.97 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15468.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16553.58, "90th_percentile": 16553.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16553.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "844", "type": "MS-DRG" } ], "description": "Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 26448.76, "minimum": 10664.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26448.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23641.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24680.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22234.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20859.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10664.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22093.81 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 26060.43, "90th_percentile": 26060.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26060.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 9507.05, "90th_percentile": 9507.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9507.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 870.92, "90th_percentile": 870.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 870.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "843", "type": "MS-DRG" } ], "description": "Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 41896.2, "minimum": 16701.84, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41896.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 37449.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 39094.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35221.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33042.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16701.84 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34997.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11924.14, "90th_percentile": 11924.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11924.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 8311.26, "90th_percentile": 8311.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8311.26, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10505.94, "90th_percentile": 10505.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10505.94, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13003.09, "90th_percentile": 13708.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13521.88, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12772.99, "90th_percentile": 12772.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12772.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "842", "type": "MS-DRG" } ], "description": "Lymphoma And Non-Acute Leukemia Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 23277.39, "minimum": 9057.18, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23277.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20806.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21720.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19568.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18358.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9057.18 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19444.63 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18727.82, "90th_percentile": 20661.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18727.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10202.61, "90th_percentile": 10202.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10202.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8919.54, "90th_percentile": 8919.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8919.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "841", "type": "MS-DRG" } ], "description": "Lymphoma And Non-Acute Leukemia With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 34699.19, "minimum": 13879.75, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34699.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31016.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 32378.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29170.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27366.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13879.75 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28985.77 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12264.97, "90th_percentile": 12264.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12264.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10759.12, "90th_percentile": 10759.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10759.12, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32695.94, "90th_percentile": 32695.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32695.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10031.93, "90th_percentile": 10031.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10031.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10388.11, "90th_percentile": 10388.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10388.11, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 16395.41, "90th_percentile": 16395.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16395.41, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12705.79, "90th_percentile": 12813.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12705.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 30762.59, "90th_percentile": 30762.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30762.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6404.02, "90th_percentile": 6404.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6404.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1171.45, "90th_percentile": 1171.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1171.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28942.14, "90th_percentile": 28942.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28942.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "840", "type": "MS-DRG" } ], "description": "Lymphoma And Non-Acute Leukemia With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 70584.61, "minimum": 26332.23, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70584.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 63092.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 65864.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 59338.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 55667.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26332.23 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 58962.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 28656.0, "90th_percentile": 28656.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28656.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2260.46, "90th_percentile": 24930.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22964.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 25837.59, "90th_percentile": 25837.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25837.59, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38011.3, "90th_percentile": 994330.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67454.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22407.73, "90th_percentile": 61596.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22871.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 108169.28, "90th_percentile": 108169.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 108169.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21320.93, "90th_percentile": 25581.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23998.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 62564.99, "90th_percentile": 62564.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62564.99, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 24186.19, "90th_percentile": 24186.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24186.19, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25837.59, "90th_percentile": 25837.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25837.59, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11117.59, "90th_percentile": 25180.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23343.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 53898.22, "90th_percentile": 53898.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53898.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "839", "type": "MS-DRG" } ], "description": "Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 30326.11, "minimum": 12423.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30326.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27107.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28298.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25494.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23917.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12423.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25332.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8169.71, "90th_percentile": 8169.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8169.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8836.79, "90th_percentile": 8927.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8836.79, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10000.0, "90th_percentile": 10000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10000.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26651.51, "90th_percentile": 26651.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26651.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "838", "type": "MS-DRG" } ], "description": "Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent", "standard_charges": [ { "billing_class": "facility", "maximum": 44883.88, "minimum": 17420.96, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44883.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 40119.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 41882.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37732.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35398.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17420.96 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 37493.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 24520.35, "90th_percentile": 24520.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24520.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39482.55, "90th_percentile": 39482.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39482.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8455.89, "90th_percentile": 8455.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8455.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8948.06, "90th_percentile": 10538.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8948.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8836.79, "90th_percentile": 8836.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8836.79, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10000.0, "90th_percentile": 35400.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10000.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16324.06, "90th_percentile": 16324.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16324.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "837", "type": "MS-DRG" } ], "description": "Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc", "standard_charges": [ { "billing_class": "facility", "maximum": 110805.49, "minimum": 38519.89, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110805.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 99044.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 103395.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 93151.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87388.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38519.89 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 92560.71 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 261877.15, "90th_percentile": 726237.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 261877.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 23011.28, "90th_percentile": 23011.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23011.28, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37818.43, "90th_percentile": 37818.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37818.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 212936.46, "90th_percentile": 212936.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 212936.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "836", "type": "MS-DRG" } ], "description": "Acute Leukemia Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28121.86, "minimum": 10681.01, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28121.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25136.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26241.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23641.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22178.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10681.01 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23491.43 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8439.97, "90th_percentile": 8439.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8439.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "835", "type": "MS-DRG" } ], "description": "Acute Leukemia With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 47267.39, "minimum": 17408.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47267.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 42250.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 44106.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39736.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37278.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17408.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 39484.53 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14119.94, "90th_percentile": 14119.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14119.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16077.28, "90th_percentile": 16077.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16077.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14626.84, "90th_percentile": 14626.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14626.84, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23941.36, "90th_percentile": 23941.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23941.36, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 38499.7, "90th_percentile": 62000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38499.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17149.44, "90th_percentile": 17149.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17149.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 192308.2, "90th_percentile": 192308.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 192308.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "834", "type": "MS-DRG" } ], "description": "Acute Leukemia With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 122315.82, "minimum": 43844.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 122315.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 109333.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 114136.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 102827.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 96466.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43844.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 102175.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 437071.45, "90th_percentile": 776101.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 437071.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 45071.46, "90th_percentile": 45071.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45071.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38629.08, "90th_percentile": 42583.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38647.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 449330.38, "90th_percentile": 449330.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 449330.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 57796.4, "90th_percentile": 57796.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57796.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40604.93, "90th_percentile": 40604.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40604.93, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 62663.25, "90th_percentile": 62663.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62663.25, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 386879.77, "90th_percentile": 386879.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 386879.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22238.44, "90th_percentile": 22238.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22238.44, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 96473.49, "90th_percentile": 96473.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 96473.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42657.87, "90th_percentile": 61346.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42657.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 96473.49, "90th_percentile": 96473.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 96473.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "833", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 11503.69, "minimum": 5271.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11503.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 10282.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 10734.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9670.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 9072.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5271.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 9609.54 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5664.5, "90th_percentile": 11503.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 9790.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11492.78, "90th_percentile": 11492.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11492.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3461.5, "90th_percentile": 3461.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3461.5, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4162.95, "90th_percentile": 10282.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 8612.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3225.54, "90th_percentile": 3947.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3947.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3259.08, "90th_percentile": 3259.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3259.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 1410.0, "90th_percentile": 10520.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2196.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2685.65, "90th_percentile": 3982.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3200.46, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3051.18, "90th_percentile": 3733.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 3051.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6080.5, "90th_percentile": 6080.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6080.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 5809.55, "90th_percentile": 11365.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7550.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 3370.83, "90th_percentile": 8250.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3370.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7308.57, "90th_percentile": 9670.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7419.35, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3178.5, "90th_percentile": 4215.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3370.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7133.54, "90th_percentile": 20977.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7133.54, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7721.35, "90th_percentile": 9594.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 8820.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8846.63, "90th_percentile": 9594.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 9072.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "832", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses Without O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 16538.5, "minimum": 6814.41, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16538.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14783.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 15432.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13903.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13043.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6814.41 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13815.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15052.13, "90th_percentile": 17474.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16181.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15480.95, "90th_percentile": 15480.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15480.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4125.04, "90th_percentile": 4215.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4125.04, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7703.75, "90th_percentile": 15046.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 11893.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3947.24, "90th_percentile": 3947.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3947.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6517.13, "90th_percentile": 6517.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6517.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 701.2, "90th_percentile": 701.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 701.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3200.46, "90th_percentile": 3254.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3200.46, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4883.92, "90th_percentile": 4883.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4883.92, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3051.18, "90th_percentile": 4469.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 3733.87, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 12226.76, "90th_percentile": 12226.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12226.76, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 3461.5, "90th_percentile": 4215.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4125.04, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5051.04, "90th_percentile": 49714.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13771.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3370.83, "90th_percentile": 4937.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4125.04, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25100.76, "90th_percentile": 25100.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25100.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11380.23, "90th_percentile": 13795.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11966.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 3196.48, "90th_percentile": 3911.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3911.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9237.52, "90th_percentile": 9237.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9237.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11381.47, "90th_percentile": 13795.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13045.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "831", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses Without O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25470.57, "minimum": 10548.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25470.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22767.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23767.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21412.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20087.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10548.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21276.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 19368.31, "90th_percentile": 19368.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19368.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7939.79, "90th_percentile": 7939.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7939.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4937.33, "90th_percentile": 4937.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4937.33, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20420.63, "90th_percentile": 90988.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22607.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3947.24, "90th_percentile": 4811.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4724.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9560.93, "90th_percentile": 9560.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9560.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3200.46, "90th_percentile": 4767.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3830.69, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3733.87, "90th_percentile": 9250.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4469.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 47736.16, "90th_percentile": 47736.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47736.16, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11101.85, "90th_percentile": 11101.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11101.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 2260.0, "90th_percentile": 2260.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2260.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4125.04, "90th_percentile": 4937.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4937.33, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7041.39, "90th_percentile": 7041.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7041.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19649.4, "90th_percentile": 19649.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19649.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "830", "type": "MS-DRG" } ], "description": "Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 32364.37, "minimum": 12898.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32364.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 28929.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30200.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27207.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25524.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12898.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27035.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 85584.86, "90th_percentile": 85584.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 85584.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "829", "type": "MS-DRG" } ], "description": "Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 68243.15, "minimum": 25750.57, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 68243.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 60999.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 63679.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57370.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 53821.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25750.57 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 57006.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 78067.11, "90th_percentile": 78067.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78067.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24223.44, "90th_percentile": 25020.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24223.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10473.63, "90th_percentile": 10473.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10473.63, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61003.73, "90th_percentile": 61003.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61003.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19228.93, "90th_percentile": 19228.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19228.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 37288.78, "90th_percentile": 37288.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37288.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74865.8, "90th_percentile": 74865.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74865.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 22444.75, "90th_percentile": 22444.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22444.75, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25016.3, "90th_percentile": 25016.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25016.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 45516.5, "90th_percentile": 45516.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45516.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9931.89, "90th_percentile": 9931.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9931.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36524.13, "90th_percentile": 36524.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36524.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 54391.02, "90th_percentile": 54391.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54391.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "828", "type": "MS-DRG" } ], "description": "Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C", "standard_charges": [ { "billing_class": "facility", "maximum": 35471.57, "minimum": 14441.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35471.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31706.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33099.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29820.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27975.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14441.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29630.96 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 38971.55, "90th_percentile": 38971.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38971.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31484.16, "90th_percentile": 31484.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31484.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13920.12, "90th_percentile": 13920.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13920.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12512.62, "90th_percentile": 12512.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12512.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32222.01, "90th_percentile": 32222.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32222.01, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11048.35, "90th_percentile": 11048.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11048.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "827", "type": "MS-DRG" } ], "description": "Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 52222.52, "minimum": 19158.95, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 52222.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 46679.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 48730.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43902.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41186.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19158.95 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 43623.77 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 237419.51, "90th_percentile": 237419.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 237419.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19840.38, "90th_percentile": 19840.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19840.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18733.31, "90th_percentile": 18733.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18733.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74103.91, "90th_percentile": 74103.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74103.91, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18783.53, "90th_percentile": 18783.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18783.53, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 53324.64, "90th_percentile": 53324.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53324.64, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42452.63, "90th_percentile": 42452.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42452.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17043.84, "90th_percentile": 17043.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17043.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 336563.78, "90th_percentile": 336563.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 336563.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "826", "type": "MS-DRG" } ], "description": "Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 105679.95, "minimum": 37537.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 105679.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 94463.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 98612.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88842.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 83346.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37537.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 88279.12 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36904.66, "90th_percentile": 36904.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36904.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 94468.94, "90th_percentile": 94468.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 94468.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36390.88, "90th_percentile": 36390.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36390.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 196673.47, "90th_percentile": 196673.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 196673.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36913.52, "90th_percentile": 36913.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36913.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 62072.85, "90th_percentile": 62072.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62072.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69062.86, "90th_percentile": 69062.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69062.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "825", "type": "MS-DRG" } ], "description": "Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 27236.62, "minimum": 11689.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27236.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24345.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25415.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22897.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21480.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11689.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22751.95 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22547.69, "90th_percentile": 22547.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22547.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 28982.92, "90th_percentile": 28982.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28982.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "824", "type": "MS-DRG" } ], "description": "Lymphoma And Non-Acute Leukemia With Other Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 48672.71, "minimum": 18804.83, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48672.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 43506.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 45417.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40917.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38386.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18804.83 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 40658.46 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 48628.73, "90th_percentile": 48628.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48628.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17467.76, "90th_percentile": 18268.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17467.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 49932.41, "90th_percentile": 49932.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49932.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9074.83, "90th_percentile": 9074.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9074.83, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 43200.61, "90th_percentile": 43200.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43200.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18449.73, "90th_percentile": 18449.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18449.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13008.64, "90th_percentile": 13008.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13008.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15915.13, "90th_percentile": 15915.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15915.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44457.59, "90th_percentile": 44457.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44457.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39651.27, "90th_percentile": 39651.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39651.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17325.28, "90th_percentile": 21301.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17659.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 41166.82, "90th_percentile": 41166.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41166.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "823", "type": "MS-DRG" } ], "description": "Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 103555.38, "minimum": 36815.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 103555.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 92563.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 96630.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 87056.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 81670.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36815.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 86504.37 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 168356.72, "90th_percentile": 168356.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 168356.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32893.28, "90th_percentile": 35010.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33587.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18203.69, "90th_percentile": 18203.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18203.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 95602.25, "90th_percentile": 95602.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 95602.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36155.59, "90th_percentile": 36155.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36155.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26300.93, "90th_percentile": 26300.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26300.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10946.38, "90th_percentile": 10946.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10946.38, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 34065.57, "90th_percentile": 34065.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34065.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 92527.75, "90th_percentile": 92527.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 92527.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 40000.0, "90th_percentile": 40000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40000.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32831.27, "90th_percentile": 36506.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34621.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 219937.02, "90th_percentile": 219937.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 219937.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "822", "type": "MS-DRG" } ], "description": "Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 25309.01, "minimum": 10560.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25309.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 22622.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 23616.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21276.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19960.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10560.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 21141.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "821", "type": "MS-DRG" } ], "description": "Lymphoma And Leukemia With Major O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 49400.82, "minimum": 18595.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 49400.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 44157.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 46097.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 41530.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38960.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18595.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 41266.68 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17725.82, "90th_percentile": 17725.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17725.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46550.0, "90th_percentile": 46550.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46550.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15830.3, "90th_percentile": 15830.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15830.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 13645.76, "90th_percentile": 13645.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13645.76, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42499.62, "90th_percentile": 42499.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42499.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "820", "type": "MS-DRG" } ], "description": "Lymphoma And Leukemia With Major O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 128844.47, "minimum": 46755.54, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 128844.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 115168.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 120228.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 108316.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 101615.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46755.54 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 107629.47 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 62714.68, "90th_percentile": 62714.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62714.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 121406.6, "90th_percentile": 121406.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121406.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 25083.2, "90th_percentile": 25083.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25083.2, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44834.15, "90th_percentile": 45880.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44834.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 44831.51, "90th_percentile": 44831.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44831.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 99040.9, "90th_percentile": 99040.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99040.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44277.76, "90th_percentile": 45196.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44277.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 231524.4, "90th_percentile": 231524.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 231524.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "819", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 18069.96, "minimum": 7888.42, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18069.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 16152.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 16861.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15190.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14251.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7888.42 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 15094.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17270.24, "90th_percentile": 17270.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17270.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8086.31, "90th_percentile": 8086.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8086.31, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16870.38, "90th_percentile": 16870.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16870.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7155.77, "90th_percentile": 7155.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7155.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15070.96, "90th_percentile": 15070.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15070.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "818", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses With O.R. Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 28504.73, "minimum": 10212.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28504.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25479.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26598.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23963.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22480.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10212.73 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23811.26 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 26866.88, "90th_percentile": 26866.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26866.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7155.77, "90th_percentile": 7155.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7155.77, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25298.9, "90th_percentile": 26386.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25479.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 11199.36, "90th_percentile": 11199.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11199.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6477.21, "90th_percentile": 8481.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6477.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22680.43, "90th_percentile": 22680.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22680.43, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 1989.45, "90th_percentile": 1989.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1989.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "817", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses With O.R. Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 56104.3, "minimum": 18929.08, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 56104.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 50149.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 52352.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 47165.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 44247.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18929.08 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 46866.39 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 564495.26, "90th_percentile": 564495.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 564495.26, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 10871.18, "90th_percentile": 10871.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10871.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14670.24, "90th_percentile": 14670.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14670.24, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44247.64, "90th_percentile": 44247.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44247.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "816", "type": "MS-DRG" } ], "description": "Reticuloendothelial And Immunity Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14593.18, "minimum": 6118.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14593.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 13044.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13617.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12268.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11509.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6118.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 12190.33 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 46914.15, "90th_percentile": 46914.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46914.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3795.9, "90th_percentile": 3795.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3795.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "815", "type": "MS-DRG" } ], "description": "Reticuloendothelial And Immunity Disorders With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22487.31, "minimum": 9085.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22487.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20100.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20983.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18904.54 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17735.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9085.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18784.64 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22487.31, "90th_percentile": 22487.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22487.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8100.37, "90th_percentile": 8543.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8100.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8570.36, "90th_percentile": 8570.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8570.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 3460.81, "90th_percentile": 3460.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3460.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 28271.62, "90th_percentile": 28271.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28271.62, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6404.02, "90th_percentile": 6404.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6404.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17735.1, "90th_percentile": 17735.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17735.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7643.05, "90th_percentile": 7643.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7643.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "814", "type": "MS-DRG" } ], "description": "Reticuloendothelial And Immunity Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 46260.43, "minimum": 17726.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 46260.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 41350.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 43166.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 38890.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36484.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17726.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 38643.38 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16337.96, "90th_percentile": 16337.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16337.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4073.72, "90th_percentile": 4073.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4073.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35182.6, "90th_percentile": 35182.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35182.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "813", "type": "MS-DRG" } ], "description": "Coagulation Disorders", "standard_charges": [ { "billing_class": "facility", "maximum": 34256.57, "minimum": 13055.79, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34256.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 30620.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 31965.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28798.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27017.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13055.79 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 28616.03 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10954.86, "90th_percentile": 12692.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12564.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4760.81, "90th_percentile": 4760.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4760.81, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23561.95, "90th_percentile": 30622.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30149.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12174.71, "90th_percentile": 12583.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12555.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 31066.98, "90th_percentile": 31066.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31066.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 8334.24, "90th_percentile": 23591.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14781.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7963.83, "90th_percentile": 7963.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7963.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12549.58, "90th_percentile": 15867.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12579.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16707.7, "90th_percentile": 16707.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16707.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 10957.32, "90th_percentile": 10957.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10957.32, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7873.16, "90th_percentile": 7873.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7873.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13048.22, "90th_percentile": 13048.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13048.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10887.63, "90th_percentile": 12727.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10891.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27160.52, "90th_percentile": 27160.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27160.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "812", "type": "MS-DRG" } ], "description": "Red Blood Cell Disorders Without Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20424.7, "minimum": 8341.17, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20424.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18256.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19058.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17170.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16108.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8341.17 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17061.65 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20424.7, "90th_percentile": 20424.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20424.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5764.96, "90th_percentile": 7845.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7169.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21468.43, "90th_percentile": 21578.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21468.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8645.38, "90th_percentile": 8645.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8645.38, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15302.29, "90th_percentile": 19244.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18637.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6382.38, "90th_percentile": 8098.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6382.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6468.69, "90th_percentile": 8177.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7836.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4499.49, "90th_percentile": 7743.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5509.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 19957.08, "90th_percentile": 20059.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20059.23, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6036.13, "90th_percentile": 7861.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 7523.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 656.87, "90th_percentile": 656.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 656.87, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5637.6, "90th_percentile": 5637.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5637.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 7851.33, "90th_percentile": 7851.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7851.33, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6086.64, "90th_percentile": 6760.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6669.87, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8128.15, "90th_percentile": 8128.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8128.15, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6312.76, "90th_percentile": 7933.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 7042.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12814.43, "90th_percentile": 16948.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15779.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "811", "type": "MS-DRG" } ], "description": "Red Blood Cell Disorders With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31133.89, "minimum": 12116.13, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31133.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27829.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29051.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26173.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24554.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12116.13 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26007.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1092.25, "90th_percentile": 11785.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 10524.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8645.38, "90th_percentile": 8645.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8645.38, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27634.33, "90th_percentile": 27634.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27634.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10003.39, "90th_percentile": 10003.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10003.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10488.83, "90th_percentile": 11567.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10729.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7825.56, "90th_percentile": 7825.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7825.56, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 30578.97, "90th_percentile": 30578.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30578.97, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 9864.49, "90th_percentile": 9864.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9864.49, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9366.97, "90th_percentile": 11530.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 11464.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 11050.0, "90th_percentile": 11050.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11050.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8645.38, "90th_percentile": 10453.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8645.38, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10268.09, "90th_percentile": 12233.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11944.09, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24424.71, "90th_percentile": 24424.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24424.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 13951.56, "90th_percentile": 13951.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13951.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10069.64, "90th_percentile": 11877.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 11598.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24556.03, "90th_percentile": 25968.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24556.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "810", "type": "MS-DRG" } ], "description": "Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ", "standard_charges": [ { "billing_class": "facility", "maximum": 21062.07, "minimum": 9338.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21062.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18826.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19653.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17706.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16610.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9338.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17594.08 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9070.98, "90th_percentile": 9070.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9070.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18828.51, "90th_percentile": 897380.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18828.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "809", "type": "MS-DRG" } ], "description": "Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ", "standard_charges": [ { "billing_class": "facility", "maximum": 27409.24, "minimum": 11041.34, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27409.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 24500.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 25576.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23042.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21616.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11041.34 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22896.15 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 23988.73, "90th_percentile": 23988.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23988.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10228.62, "90th_percentile": 10228.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10228.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7366.0, "90th_percentile": 7366.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7366.0, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19324.8, "90th_percentile": 26396.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22277.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8578.34, "90th_percentile": 10725.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10016.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 13044.51, "90th_percentile": 13044.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13044.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 10204.78, "90th_percentile": 10204.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10204.78, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7667.1, "90th_percentile": 7667.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7667.1, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 44730.7, "90th_percentile": 44730.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44730.7, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 26918.8, "90th_percentile": 26918.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26918.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10552.74, "90th_percentile": 10552.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10552.74, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12460.57, "90th_percentile": 12460.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12460.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10594.55, "90th_percentile": 10935.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10823.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "808", "type": "MS-DRG" } ], "description": "Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ", "standard_charges": [ { "billing_class": "facility", "maximum": 50688.84, "minimum": 18356.74, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50688.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 45308.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 47299.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42612.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39976.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18356.74 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 42342.62 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17794.84, "90th_percentile": 18210.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18158.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 543966.2, "90th_percentile": 543966.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 543966.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18145.45, "90th_percentile": 18153.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18145.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 28567.23, "90th_percentile": 28567.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28567.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16181.6, "90th_percentile": 18154.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16955.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26469.63, "90th_percentile": 26469.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26469.63, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 18174.48, "90th_percentile": 18174.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18174.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12460.57, "90th_percentile": 12460.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12460.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 39974.9, "90th_percentile": 42274.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39974.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18043.84, "90th_percentile": 18043.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18043.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35887.41, "90th_percentile": 35887.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35887.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "807", "type": "MS-DRG" } ], "description": "Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14101.87, "minimum": 6446.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14101.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12605.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13158.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11855.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11121.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6446.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11779.92 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8091.9, "90th_percentile": 11424.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "341", "median_amount": 10803.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8642.4, "90th_percentile": 11272.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "59", "median_amount": 10803.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4617.48, "90th_percentile": 5932.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "81", "median_amount": 4617.48, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8864.03, "90th_percentile": 13288.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "755", "median_amount": 12247.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4418.45, "90th_percentile": 4813.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "80", "median_amount": 4418.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4781.96, "90th_percentile": 4781.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4781.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10735.5, "90th_percentile": 10735.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10735.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 400.0, "90th_percentile": 6058.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 3787.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3582.53, "90th_percentile": 4857.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "101", "median_amount": 4182.6, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2506.26, "90th_percentile": 4146.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3831.97, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4179.62, "90th_percentile": 4635.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "330", "median_amount": 4179.62, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4884.36, "90th_percentile": 4884.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4884.36, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9048.96, "90th_percentile": 18041.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 12145.56, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 9067.28, "90th_percentile": 11216.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "112", "median_amount": 11045.25, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9429.9, "90th_percentile": 15904.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9429.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4343.19, "90th_percentile": 4343.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4343.19, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4617.48, "90th_percentile": 5767.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "91", "median_amount": 4617.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8312.39, "90th_percentile": 12503.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "163", "median_amount": 11856.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 1925.54, "90th_percentile": 6162.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 4036.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9814.18, "90th_percentile": 13724.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9852.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4617.48, "90th_percentile": 5121.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "114", "median_amount": 4617.48, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8944.56, "90th_percentile": 13925.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11356.38, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9988.75, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "191", "median_amount": 13346.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4378.65, "90th_percentile": 5625.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "82", "median_amount": 4378.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10573.49, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "387", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "806", "type": "MS-DRG" } ], "description": "Vaginal Delivery Without Sterilization Or D&C With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 16011.78, "minimum": 7066.02, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16011.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14312.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14941.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13460.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12627.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7066.02 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13375.34 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8526.91, "90th_percentile": 11424.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "57", "median_amount": 10803.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10495.79, "90th_percentile": 11424.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10803.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4617.48, "90th_percentile": 10197.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5030.58, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9292.4, "90th_percentile": 15088.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "98", "median_amount": 13139.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4418.45, "90th_percentile": 4900.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 4813.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 468.78, "90th_percentile": 6628.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4474.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3582.53, "90th_percentile": 5140.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 3973.38, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3940.45, "90th_percentile": 8253.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3940.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4179.62, "90th_percentile": 5452.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "87", "median_amount": 4553.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9459.4, "90th_percentile": 12624.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10578.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 9945.7, "90th_percentile": 13972.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 11216.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 9333.0, "90th_percentile": 9333.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9333.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4617.48, "90th_percentile": 6444.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 5030.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11373.49, "90th_percentile": 14196.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 13759.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 4024.16, "90th_percentile": 5740.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4800.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4617.48, "90th_percentile": 5121.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 5030.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3072.52, "90th_percentile": 3072.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3072.52, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10581.28, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4107.57, "90th_percentile": 4856.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 4378.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10246.94, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "805", "type": "MS-DRG" } ], "description": "Vaginal Delivery Without Sterilization Or D&C With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22084.52, "minimum": 9591.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22084.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19740.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20607.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18565.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17417.35 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9591.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18448.18 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 10520.03, "90th_percentile": 10803.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 10803.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4716.21, "90th_percentile": 4716.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4716.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5030.58, "90th_percentile": 6556.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5030.58, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12362.26, "90th_percentile": 19602.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 16678.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4813.75, "90th_percentile": 5759.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4900.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4646.12, "90th_percentile": 5315.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5030.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3903.04, "90th_percentile": 5902.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4603.07, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17854.61, "90th_percentile": 17854.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17854.61, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4553.55, "90th_percentile": 6243.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 4635.61, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13082.03, "90th_percentile": 13082.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13082.03, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 11216.0, "90th_percentile": 11216.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11216.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5030.58, "90th_percentile": 5932.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5030.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15755.15, "90th_percentile": 19579.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18567.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 7742.45, "90th_percentile": 7742.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7742.45, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5030.58, "90th_percentile": 5932.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5030.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14645.23, "90th_percentile": 14645.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14645.23, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12306.32, "90th_percentile": 16300.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14426.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4770.38, "90th_percentile": 5625.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4770.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6808.26, "90th_percentile": 6808.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6808.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11383.35, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "804", "type": "MS-DRG" } ], "description": "Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 24465.82, "minimum": 11741.04, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24465.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21869.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22829.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20567.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19295.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11741.04 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20437.38 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20381.44, "90th_percentile": 20381.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20381.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "803", "type": "MS-DRG" } ], "description": "Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 39390.97, "minimum": 15646.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39390.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35209.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 36756.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33115.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31066.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15646.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 32905.01 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 249287.9, "90th_percentile": 249287.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 249287.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 137828.83, "90th_percentile": 137828.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 137828.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 38578.3, "90th_percentile": 38578.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38578.3, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12450.56, "90th_percentile": 12450.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12450.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "802", "type": "MS-DRG" } ], "description": "Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 79330.78, "minimum": 32150.37, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 79330.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 70910.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 74025.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 66691.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 62565.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32150.37 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 66268.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27941.95, "90th_percentile": 27941.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27941.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 74261.82, "90th_percentile": 74261.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74261.82, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25649.27, "90th_percentile": 25649.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25649.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 54987.7, "90th_percentile": 54987.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54987.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 337104.04, "90th_percentile": 337104.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 337104.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "801", "type": "MS-DRG" } ], "description": "Splenic Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 36332.46, "minimum": 16034.76, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36332.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 32476.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33902.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30543.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28654.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16034.76 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30350.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "800", "type": "MS-DRG" } ], "description": "Splenic Procedures With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 64480.88, "minimum": 23027.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 64480.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 57636.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 60168.75 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54207.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 50853.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23027.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 53863.72 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22886.3, "90th_percentile": 22886.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22886.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 333012.77, "90th_percentile": 333012.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 333012.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 54417.19, "90th_percentile": 54417.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54417.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "799", "type": "MS-DRG" } ], "description": "Splenic Procedures With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 105221.84, "minimum": 36381.19, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 105221.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 94053.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 98185.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 88457.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 82985.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36381.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 87896.44 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35499.76, "90th_percentile": 35499.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35499.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 464709.7, "90th_percentile": 464709.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 464709.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 102659.54, "90th_percentile": 102659.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 102659.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36171.79, "90th_percentile": 36171.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36171.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 86037.08, "90th_percentile": 86037.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 86037.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "798", "type": "MS-DRG" } ], "description": "Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21427.23, "minimum": 8643.26, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21427.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19152.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19994.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18013.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16898.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8643.26 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17899.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 10572.4, "90th_percentile": 10803.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10572.4, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6836.29, "90th_percentile": 6836.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6836.29, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15346.6, "90th_percentile": 16943.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16467.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5780.39, "90th_percentile": 5780.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5780.39, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5419.11, "90th_percentile": 5823.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5419.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 8972.81, "90th_percentile": 11236.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11028.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5986.83, "90th_percentile": 5986.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5986.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5986.83, "90th_percentile": 7345.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5986.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10935.74, "90th_percentile": 10935.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10935.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "797", "type": "MS-DRG" } ], "description": "Vaginal Delivery With Sterilization And/Or D&C With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 21427.23, "minimum": 8979.52, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21427.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19152.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19994.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18013.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16898.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8979.52 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17899.11 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9525.2, "90th_percentile": 9525.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9525.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16844.63, "90th_percentile": 16844.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16844.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 11216.0, "90th_percentile": 11216.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11216.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5986.83, "90th_percentile": 5986.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5986.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6524.13, "90th_percentile": 6524.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6524.13, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12654.31, "90th_percentile": 12654.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12654.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5239.04, "90th_percentile": 5239.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5239.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13642.0, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "796", "type": "MS-DRG" } ], "description": "Vaginal Delivery With Sterilization And/Or D&C With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28252.43, "minimum": 10273.3, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28252.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25253.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26363.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23751.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22281.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10273.3 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23600.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24334.28, "90th_percentile": 24334.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24334.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6156.16, "90th_percentile": 6156.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6156.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13531.6, "90th_percentile": 13531.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13531.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "795", "type": "MS-DRG" } ], "description": "Normal Newborn", "standard_charges": [ { "billing_class": "facility", "maximum": 4421.77, "minimum": 2762.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 4421.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 3952.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 4126.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3717.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 3487.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2762.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 3693.7 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 2038.14, "90th_percentile": 4671.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "373", "median_amount": 4003.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3509.84, "90th_percentile": 4671.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "64", "median_amount": 4417.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2222.35, "90th_percentile": 2313.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "77", "median_amount": 2222.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3139.58, "90th_percentile": 4166.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "883", "median_amount": 3924.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 2126.56, "90th_percentile": 2213.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "85", "median_amount": 2126.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3924.47, "90th_percentile": 6950.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3924.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 999.33, "90th_percentile": 3010.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "79", "median_amount": 1671.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 1820.03, "90th_percentile": 2145.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "104", "median_amount": 1894.28, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 983.92, "90th_percentile": 3427.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1747.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2011.61, "90th_percentile": 2093.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "367", "median_amount": 2011.61, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3154.55, "90th_percentile": 9166.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 4718.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 3300.42, "90th_percentile": 5722.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "119", "median_amount": 4315.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2011.61, "90th_percentile": 6997.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3222.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2023.42, "90th_percentile": 2023.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2023.42, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 2222.35, "90th_percentile": 2313.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "107", "median_amount": 2222.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1935.9, "90th_percentile": 3919.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "179", "median_amount": 3919.88, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 580.71, "90th_percentile": 2867.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 1505.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1915.82, "90th_percentile": 1915.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1915.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2222.35, "90th_percentile": 2313.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "141", "median_amount": 2222.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 905.21, "90th_percentile": 5753.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 3173.28, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2160.27, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "195", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2107.4, "90th_percentile": 2193.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "84", "median_amount": 2107.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2315.2, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "510", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "794", "type": "MS-DRG" } ], "description": "Neonate With Other Significant Problems", "standard_charges": [ { "billing_class": "facility", "maximum": 32669.78, "minimum": 12672.16, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32669.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 29202.19 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 30485.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 27464.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25765.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12672.16 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 27290.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3376.99, "90th_percentile": 10737.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 6722.24, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3834.19, "90th_percentile": 10227.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 7410.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2222.35, "90th_percentile": 2632.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 2313.02, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3891.57, "90th_percentile": 11500.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "158", "median_amount": 7339.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 2126.56, "90th_percentile": 2539.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 2432.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 1216.98, "90th_percentile": 4027.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 2185.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 1820.03, "90th_percentile": 3409.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 2156.22, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2011.61, "90th_percentile": 2688.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "135", "median_amount": 2301.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5452.34, "90th_percentile": 10468.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8293.48, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 3691.4, "90th_percentile": 9698.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 6798.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6429.0, "90th_percentile": 6429.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6429.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 2222.35, "90th_percentile": 2880.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 2313.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2764.16, "90th_percentile": 12529.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 7552.94, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 3355.82, "90th_percentile": 3355.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3355.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8188.79, "90th_percentile": 8188.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8188.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2222.35, "90th_percentile": 4138.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 2542.19, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5935.92, "90th_percentile": 5935.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5935.92, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1692.91, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2107.4, "90th_percentile": 2791.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 2410.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2315.2, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "112", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "793", "type": "MS-DRG" } ], "description": "Full Term Neonate With Major Problems", "standard_charges": [ { "billing_class": "facility", "maximum": 92299.55, "minimum": 33590.93, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 92299.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 82502.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 86127.06 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 77594.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 72793.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33590.93 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 77101.88 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 7575.75, "90th_percentile": 13120.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 9233.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5613.04, "90th_percentile": 5613.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5613.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2542.19, "90th_percentile": 6273.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2542.19, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4053.42, "90th_percentile": 12420.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 7213.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 2432.61, "90th_percentile": 3983.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2432.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 2187.81, "90th_percentile": 2412.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2187.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2081.96, "90th_percentile": 10903.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3409.08, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4662.0, "90th_percentile": 4662.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4662.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2301.12, "90th_percentile": 5678.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 2383.19, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3603.14, "90th_percentile": 7216.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6032.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 5414.11, "90th_percentile": 7221.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6533.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 2880.02, "90th_percentile": 6273.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4162.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4162.67, "90th_percentile": 12795.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9306.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 5349.61, "90th_percentile": 5349.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5349.61, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2542.19, "90th_percentile": 11293.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 4162.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1796.12, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2410.69, "90th_percentile": 5805.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2410.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2448.0, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "792", "type": "MS-DRG" } ], "description": "Prematurity Without Major Problems", "standard_charges": [ { "billing_class": "facility", "maximum": 54216.52, "minimum": 20230.63, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 54216.52 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 48461.94 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 50590.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45578.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 42758.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20230.63 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 45289.45 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5830.72, "90th_percentile": 12985.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 7932.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13461.0, "90th_percentile": 13461.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13461.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2222.35, "90th_percentile": 4162.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2542.19, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7204.3, "90th_percentile": 13617.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 8551.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 2126.56, "90th_percentile": 3983.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2539.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 2445.69, "90th_percentile": 4823.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2445.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 1820.03, "90th_percentile": 2562.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2173.74, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2011.61, "90th_percentile": 2484.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 2093.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7069.89, "90th_percentile": 15820.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9423.08, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 9914.9, "90th_percentile": 13807.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12620.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 2222.35, "90th_percentile": 2654.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 2542.19, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7382.7, "90th_percentile": 16819.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 10275.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 2705.11, "90th_percentile": 2705.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2705.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2222.35, "90th_percentile": 2654.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 2542.19, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12004.85, "90th_percentile": 12004.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12004.85, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2448.0, "90th_percentile": 5508.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 2107.4, "90th_percentile": 5721.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2410.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2315.2, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "791", "type": "MS-DRG" } ], "description": "Prematurity With Major Problems", "standard_charges": [ { "billing_class": "facility", "maximum": 89854.07, "minimum": 32732.03, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 89854.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 80316.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 83845.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 75538.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 70864.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32732.03 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 75059.07 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 12759.05, "90th_percentile": 12759.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12759.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15096.25, "90th_percentile": 15096.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15096.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11383.94, "90th_percentile": 11383.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11383.94, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7661.5, "90th_percentile": 15210.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9098.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 7559.51, "90th_percentile": 7559.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7559.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22723.08, "90th_percentile": 22723.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22723.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5137.49, "90th_percentile": 5137.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5137.49, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7609.25, "90th_percentile": 10222.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7609.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 7223.25, "90th_percentile": 7223.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7223.25, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5338.77, "90th_percentile": 5338.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5338.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 2334.97, "90th_percentile": 2334.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2334.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2542.19, "90th_percentile": 11806.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2744.92, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3060.0, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3060.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2894.0, "90th_percentile": 2894.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "790", "type": "MS-DRG" } ], "description": "Extreme Immaturity Or Respiratory Distress Syndrome, Neonate", "standard_charges": [ { "billing_class": "facility", "maximum": 131568.8, "minimum": 47366.71, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 131568.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 117603.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 122770.2 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 110606.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 103764.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47366.71 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 109905.22 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5450.0, "90th_percentile": 5450.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5450.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5986.29, "90th_percentile": 5986.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5986.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2894.0, "90th_percentile": 2894.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "789", "type": "MS-DRG" } ], "description": "Neonates, Died Or Transferred To Another Acute Care Facility", "standard_charges": [ { "billing_class": "facility", "maximum": 39895.55, "minimum": 15206.15, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 39895.55 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35661.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37227.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33539.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31464.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15206.15 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33326.51 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3996.8, "90th_percentile": 3996.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3996.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3309.5, "90th_percentile": 3309.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3309.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1462.63, "90th_percentile": 1641.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1553.3, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2538.0, "90th_percentile": 9826.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 3327.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 1811.89, "90th_percentile": 1811.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1811.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 972.5, "90th_percentile": 1337.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1121.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 1412.2, "90th_percentile": 1418.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1418.41, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 1323.93, "90th_percentile": 1567.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 1397.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2718.09, "90th_percentile": 2718.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2718.09, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 2807.2, "90th_percentile": 4004.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3233.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 1462.63, "90th_percentile": 1641.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1634.88, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3477.3, "90th_percentile": 3957.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3582.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 1462.63, "90th_percentile": 6125.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1544.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4889.16, "90th_percentile": 4889.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4889.16, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2894.0, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 1386.98, "90th_percentile": 1556.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1386.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2315.2, "90th_percentile": 3060.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 2894.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "788", "type": "MS-DRG" } ], "description": "Cesarean Section Without Sterilization Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 20028.56, "minimum": 8656.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20028.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17902.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18689.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16837.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15795.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8656.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16730.74 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 10958.14, "90th_percentile": 13815.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "101", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6729.69, "90th_percentile": 6729.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6729.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12126.2, "90th_percentile": 13815.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5666.17, "90th_percentile": 7956.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 6739.4, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14216.1, "90th_percentile": 19753.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "225", "median_amount": 17770.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5421.94, "90th_percentile": 6864.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 5421.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 1211.1, "90th_percentile": 13626.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 4884.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4396.17, "90th_percentile": 6507.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 5299.19, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8824.93, "90th_percentile": 8824.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8824.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5128.86, "90th_percentile": 6737.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "112", "median_amount": 5128.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18755.55, "90th_percentile": 25919.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20828.61, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 12293.97, "90th_percentile": 18510.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 14248.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 15965.28, "90th_percentile": 18416.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15965.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5666.17, "90th_percentile": 6830.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 5666.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 15232.95, "90th_percentile": 18810.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "70", "median_amount": 17749.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 5210.93, "90th_percentile": 7482.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6569.46, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5666.17, "90th_percentile": 7079.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 5666.17, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6343.57, "90th_percentile": 6343.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6343.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5797.64, "90th_percentile": 26332.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14959.35, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11591.3, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "56", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5373.09, "90th_percentile": 6390.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 5373.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11067.84, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "140", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "787", "type": "MS-DRG" } ], "description": "Cesarean Section Without Sterilization With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23498.7, "minimum": 9883.46, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23498.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21004.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21927.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19754.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18532.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9883.46 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19629.5 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 10528.39, "90th_percentile": 13815.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6811.99, "90th_percentile": 6811.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6811.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9924.19, "90th_percentile": 13815.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12622.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5666.17, "90th_percentile": 7956.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5666.17, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16494.34, "90th_percentile": 22140.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "105", "median_amount": 20079.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5421.94, "90th_percentile": 7824.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 5508.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 2960.92, "90th_percentile": 12382.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6709.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4396.17, "90th_percentile": 6528.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5228.85, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7291.37, "90th_percentile": 7291.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7291.37, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5128.86, "90th_percentile": 7202.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "62", "median_amount": 6100.32, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19435.6, "90th_percentile": 42060.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23069.07, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 12508.17, "90th_percentile": 19961.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 14248.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10784.99, "90th_percentile": 10784.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10784.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5666.17, "90th_percentile": 6739.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5666.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18879.9, "90th_percentile": 21910.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 20831.45, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 2470.28, "90th_percentile": 2470.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2470.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5666.17, "90th_percentile": 7956.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 6739.4, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7223.21, "90th_percentile": 7223.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7223.21, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10838.15, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 12994.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5373.09, "90th_percentile": 7631.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 6390.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7411.46, "90th_percentile": 7411.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7411.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10059.25, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "79", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "786", "type": "MS-DRG" } ], "description": "Cesarean Section Without Sterilization With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 35759.27, "minimum": 14020.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 35759.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 31963.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 33367.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30061.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28202.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14020.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 29871.29 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 12405.83, "90th_percentile": 46119.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13064.0, "90th_percentile": 13064.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7956.6, "90th_percentile": 8246.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7956.6, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19428.95, "90th_percentile": 31739.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 27115.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6448.91, "90th_percentile": 9056.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 6448.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10273.73, "90th_percentile": 10273.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10273.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 17318.47, "90th_percentile": 17318.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17318.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5299.19, "90th_percentile": 6507.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5617.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5188.73, "90th_percentile": 7202.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 6100.32, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18610.32, "90th_percentile": 18610.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18610.32, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 13537.0, "90th_percentile": 14248.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14248.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2000.0, "90th_percentile": 2000.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2000.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6739.4, "90th_percentile": 7956.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6739.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24791.85, "90th_percentile": 32115.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 31565.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 4188.85, "90th_percentile": 4188.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4188.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5732.31, "90th_percentile": 13453.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6739.4, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12661.92, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 14426.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5373.09, "90th_percentile": 12781.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6390.81, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11805.6, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "785", "type": "MS-DRG" } ], "description": "Cesarean Section With Sterilization Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 19362.41, "minimum": 8648.7, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19362.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 17307.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 18067.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16277.51 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15270.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8648.7 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 16174.28 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 12887.45, "90th_percentile": 13815.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13064.0, "90th_percentile": 13064.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5991.74, "90th_percentile": 5991.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5991.74, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11867.6, "90th_percentile": 19732.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 17157.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5733.47, "90th_percentile": 6407.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5733.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 8993.1, "90th_percentile": 8997.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8993.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5785.12, "90th_percentile": 6377.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5785.12, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5423.55, "90th_percentile": 5978.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 5423.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20516.28, "90th_percentile": 29143.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26821.06, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 13537.0, "90th_percentile": 25968.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14248.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6605.25, "90th_percentile": 6605.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6605.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 14481.44, "90th_percentile": 17137.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 17137.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 8961.39, "90th_percentile": 11155.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9201.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5991.74, "90th_percentile": 6695.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6082.4, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 19842.45, "90th_percentile": 19842.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19842.45, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10189.37, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7545.05, "90th_percentile": 7545.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7545.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11070.91, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "784", "type": "MS-DRG" } ], "description": "Cesarean Section With Sterilization With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 23967.87, "minimum": 9443.14, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23967.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21423.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22365.03 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20149.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18902.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9443.14 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20021.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 11303.3, "90th_percentile": 13815.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13064.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10000.97, "90th_percentile": 10000.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10000.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5991.74, "90th_percentile": 5991.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5991.74, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16735.24, "90th_percentile": 21789.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 20509.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 7276.12, "90th_percentile": 9373.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7276.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5785.12, "90th_percentile": 5785.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5785.12, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5423.55, "90th_percentile": 6060.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 5978.89, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 12818.07, "90th_percentile": 15751.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13537.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6739.4, "90th_percentile": 6739.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6739.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20798.1, "90th_percentile": 21247.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21247.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 5587.78, "90th_percentile": 5587.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5587.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5991.74, "90th_percentile": 6695.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 6605.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8580.17, "90th_percentile": 8580.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8580.17, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13528.55, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13590.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 7545.05, "90th_percentile": 7545.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7545.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12622.67, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 14426.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "783", "type": "MS-DRG" } ], "description": "Cesarean Section With Sterilization With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40765.3, "minimum": 20276.45, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40765.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36438.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 38039.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34270.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 32150.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20276.45 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 34053.05 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13064.0, "90th_percentile": 13815.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13815.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11172.67, "90th_percentile": 11172.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11172.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6695.91, "90th_percentile": 6695.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6695.91, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31167.4, "90th_percentile": 38411.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31167.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 5409.47, "90th_percentile": 5409.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5409.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5978.89, "90th_percentile": 8158.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5978.89, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 14248.0, "90th_percentile": 14248.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14248.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 13210.5, "90th_percentile": 13210.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13210.5, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35954.75, "90th_percentile": 35954.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35954.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6605.25, "90th_percentile": 9012.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6605.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12363.56, "90th_percentile": 12363.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12363.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "779", "type": "MS-DRG" } ], "description": "Abortion Without D&C", "standard_charges": [ { "billing_class": "facility", "maximum": 20685.85, "minimum": 7743.98, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20685.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18490.24 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19302.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17390.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16314.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7743.98 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17279.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18027.22, "90th_percentile": 18027.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18027.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18492.21, "90th_percentile": 22374.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18492.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3964.45, "90th_percentile": 3964.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3964.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 6948.37, "90th_percentile": 6948.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6948.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 2652.01, "90th_percentile": 2652.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2652.01, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11398.59, "90th_percentile": 11398.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11398.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 3327.48, "90th_percentile": 3327.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3327.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17281.65, "90th_percentile": 17281.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17281.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 3928.74, "90th_percentile": 3928.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3928.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16316.0, "90th_percentile": 16316.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16316.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "776", "type": "MS-DRG" } ], "description": "Postpartum And Post Abortion Diagnoses Without O.R. Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 15788.26, "minimum": 6294.88, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 15788.26 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 14112.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 14732.42 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 13272.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 12451.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6294.88 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 13188.63 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 6172.55, "90th_percentile": 143073.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10089.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5080.99, "90th_percentile": 5080.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5080.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16682.34, "90th_percentile": 16682.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16682.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3019.09, "90th_percentile": 9556.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4103.64, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6465.3, "90th_percentile": 14114.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 10558.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 3840.0, "90th_percentile": 3926.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3840.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4021.75, "90th_percentile": 4021.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4021.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 3113.51, "90th_percentile": 4740.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3183.86, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2732.79, "90th_percentile": 4839.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 3632.43, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 9761.2, "90th_percentile": 15507.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14229.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 3019.09, "90th_percentile": 6038.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3019.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6046.55, "90th_percentile": 13998.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 10946.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 4654.97, "90th_percentile": 4654.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4654.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3109.75, "90th_percentile": 4103.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 4012.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2392.67, "90th_percentile": 2392.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2392.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 6803.62, "90th_percentile": 6803.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6803.62, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13169.78, "90th_percentile": 13169.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13169.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 3805.41, "90th_percentile": 9062.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3805.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4564.96, "90th_percentile": 4564.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4564.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11741.0, "90th_percentile": 13169.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 12453.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "770", "type": "MS-DRG" } ], "description": "Abortion With D&C, Aspiration Curettage Or Hysterotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 23810.74, "minimum": 8997.38, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23810.74 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21283.45 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22218.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20017.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18778.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8997.38 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 19890.16 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 25157.96, "90th_percentile": 25157.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25157.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3846.92, "90th_percentile": 3846.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3846.92, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4693.62, "90th_percentile": 4693.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4693.62, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3482.13, "90th_percentile": 9702.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4400.27, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6078.45, "90th_percentile": 6078.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6078.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16448.89, "90th_percentile": 16448.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16448.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "769", "type": "MS-DRG" } ], "description": "Postpartum And Post Abortion Diagnoses With O.R. Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 30751.02, "minimum": 14333.27, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30751.02 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27487.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28694.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25851.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24252.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14333.27 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25687.69 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 32487.9, "90th_percentile": 32487.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32487.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27487.09, "90th_percentile": 222646.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27487.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 3670.67, "90th_percentile": 10970.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5823.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 45523.23, "90th_percentile": 45523.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45523.23, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 4138.13, "90th_percentile": 4138.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4138.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28531.3, "90th_percentile": 33152.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28531.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8470.64, "90th_percentile": 8470.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8470.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26265.68, "90th_percentile": 31190.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26265.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 24252.33, "90th_percentile": 31190.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25647.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "768", "type": "MS-DRG" } ], "description": "Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C", "standard_charges": [ { "billing_class": "facility", "maximum": 24262.22, "minimum": 9532.44, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24262.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21687.01 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22639.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20396.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19134.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9532.44 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20267.3 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 7801.34, "90th_percentile": 11424.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 10803.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9276.85, "90th_percentile": 11424.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10769.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5037.13, "90th_percentile": 5693.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5602.37, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11903.06, "90th_percentile": 21533.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "62", "median_amount": 16328.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 4505.21, "90th_percentile": 6979.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5360.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 4689.54, "90th_percentile": 6625.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5576.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4346.67, "90th_percentile": 5409.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4417.01, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5752.69, "90th_percentile": 5752.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5752.69, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4559.47, "90th_percentile": 6520.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 5071.11, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 9326.81, "90th_percentile": 18712.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15585.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 9275.96, "90th_percentile": 11216.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10452.71, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 5037.13, "90th_percentile": 7128.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5602.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 12793.74, "90th_percentile": 21099.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 16476.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5037.13, "90th_percentile": 7203.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5602.37, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11314.79, "90th_percentile": 14125.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 13335.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4228.84, "90th_percentile": 6830.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5312.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 10955.58, "90th_percentile": 14426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 13642.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "761", "type": "MS-DRG" } ], "description": "Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14028.84, "minimum": 5641.0, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14028.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12539.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13090.67 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11793.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11064.09 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.0 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11718.91 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11896.07, "90th_percentile": 11896.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11896.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 4809.17, "90th_percentile": 4809.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4809.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 2466.0, "90th_percentile": 2466.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2466.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "760", "type": "MS-DRG" } ], "description": "Menstrual And Other Female Reproductive System Disorders With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21810.1, "minimum": 9034.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21810.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 19495.16 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 20351.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18335.23 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17200.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9034.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18218.94 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13098.95, "90th_percentile": 13098.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13098.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8313.71, "90th_percentile": 8313.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8313.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19359.16, "90th_percentile": 19497.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19497.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 4896.61, "90th_percentile": 4896.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4896.61, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4590.57, "90th_percentile": 4590.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4590.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18171.8, "90th_percentile": 18171.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18171.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 5071.49, "90th_percentile": 5071.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5071.49, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18220.79, "90th_percentile": 18220.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18220.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8389.68, "90th_percentile": 8389.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8389.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17178.84, "90th_percentile": 17178.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17178.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "759", "type": "MS-DRG" } ], "description": "Infections, Female Reproductive System Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 14161.63, "minimum": 6363.99, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 14161.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 12658.5 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 13214.57 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11905.34 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 11168.81 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6363.99 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 11829.83 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 12975.1, "90th_percentile": 12975.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12975.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13837.39, "90th_percentile": 13837.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13837.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4068.44, "90th_percentile": 4808.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4068.44, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 13019.17, "90th_percentile": 13019.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13019.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4403.99, "90th_percentile": 4403.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4403.99, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11170.56, "90th_percentile": 11170.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11170.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "758", "type": "MS-DRG" } ], "description": "Infections, Female Reproductive System With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 22558.13, "minimum": 8813.33, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22558.13 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20163.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21049.56 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 18964.08 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17790.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8813.33 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18843.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17811.45, "90th_percentile": 17811.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17811.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 700.37, "90th_percentile": 700.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 700.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20163.79, "90th_percentile": 20163.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20163.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 4808.25, "90th_percentile": 4808.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4808.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7826.4, "90th_percentile": 7826.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7826.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7942.56, "90th_percentile": 7942.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7942.56, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 3844.96, "90th_percentile": 3844.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3844.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 17790.86, "90th_percentile": 17790.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17790.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 5037.22, "90th_percentile": 5037.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5037.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "757", "type": "MS-DRG" } ], "description": "Infections, Female Reproductive System With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 31319.79, "minimum": 12330.47, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31319.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27995.49 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 29225.3 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26329.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24700.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12330.47 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 26162.8 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9069.14, "90th_percentile": 9069.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9069.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11057.04, "90th_percentile": 11057.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11057.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9191.46, "90th_percentile": 9191.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9191.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "756", "type": "MS-DRG" } ], "description": "Malignancy, Female Reproductive System Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21132.89, "minimum": 8669.66, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21132.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18889.83 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19719.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17765.91 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16666.82 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8669.66 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17653.24 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 4308.1, "90th_percentile": 4308.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4308.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "755", "type": "MS-DRG" } ], "description": "Malignancy, Female Reproductive System With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 24567.62, "minimum": 9658.25, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 24567.62 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 21960.0 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 22924.68 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20653.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19375.69 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9658.25 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 20522.42 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22816.15, "90th_percentile": 22816.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22816.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8651.64, "90th_percentile": 9381.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9248.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20430.94, "90th_percentile": 20430.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20430.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8675.84, "90th_percentile": 8675.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8675.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8496.41, "90th_percentile": 9277.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8597.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 2544.27, "90th_percentile": 2544.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2544.27, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6336.94, "90th_percentile": 6336.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6336.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9270.2, "90th_percentile": 9270.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9270.2, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "10th_percentile": 8091.59, "90th_percentile": 8091.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8091.59, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7582.92, "90th_percentile": 7582.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7582.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "754", "type": "MS-DRG" } ], "description": "Malignancy, Female Reproductive System With Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40039.41, "minimum": 15512.9, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40039.41 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35789.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37361.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33660.17 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31577.78 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15512.9 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33446.68 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12997.23, "90th_percentile": 13254.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12997.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8316.83, "90th_percentile": 8316.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8316.83, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35538.27, "90th_percentile": 38403.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37942.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8675.84, "90th_percentile": 8675.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8675.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14648.28, "90th_percentile": 14648.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14648.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 7425.27, "90th_percentile": 7425.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7425.27, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13510.65, "90th_percentile": 13510.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13510.65, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14525.59, "90th_percentile": 14604.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14581.78, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36767.36, "90th_percentile": 36767.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36767.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 16759.23, "90th_percentile": 16759.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16759.23, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33396.06, "90th_percentile": 33396.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33396.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14699.32, "90th_percentile": 14699.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14699.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "750", "type": "MS-DRG" } ], "description": "Other Female Reproductive System O.R. Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 28537.92, "minimum": 12671.39, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 28537.92 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 25508.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 26629.46 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23991.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22506.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12671.39 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 23838.99 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 21868.63, "90th_percentile": 21868.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21868.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "749", "type": "MS-DRG" } ], "description": "Other Female Reproductive System O.R. Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 57283.88, "minimum": 21150.1, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 57283.88 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 51203.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 53453.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 48157.18 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 45177.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21150.1 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 47851.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20832.67, "90th_percentile": 20832.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20832.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 52897.7, "90th_percentile": 52897.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52897.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20152.01, "90th_percentile": 20152.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20152.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 13592.72, "90th_percentile": 13592.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13592.72, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 58392.5, "90th_percentile": 58392.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58392.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8144.68, "90th_percentile": 8144.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8144.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 46950.84, "90th_percentile": 46950.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46950.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "748", "type": "MS-DRG" } ], "description": "Female Reproductive System Reconstructive Procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 30146.85, "minimum": 11984.11, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30146.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 26947.04 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28130.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25343.73 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23775.84 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11984.11 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25182.99 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10829.3, "90th_percentile": 10829.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10829.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 5864.98, "90th_percentile": 5864.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5864.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11161.18, "90th_percentile": 11755.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11161.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11163.67, "90th_percentile": 11163.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11163.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8323.85, "90th_percentile": 8323.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8323.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11262.36, "90th_percentile": 11748.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11262.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "747", "type": "MS-DRG" } ], "description": "Vagina, Cervix And Vulva Procedures Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 21137.32, "minimum": 7886.87, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 21137.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 18893.79 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 19723.77 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17769.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 16670.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7886.87 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 17656.93 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7707.14, "90th_percentile": 8144.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7707.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18895.77, "90th_percentile": 18895.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18895.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6018.39, "90th_percentile": 6018.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6018.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18762.04, "90th_percentile": 18762.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18762.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5575.35, "90th_percentile": 5575.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5575.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8092.76, "90th_percentile": 8092.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8092.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18740.07, "90th_percentile": 18740.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18740.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "10th_percentile": 714.41, "90th_percentile": 714.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 714.41, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8664.91, "90th_percentile": 8664.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8664.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "746", "type": "MS-DRG" } ], "description": "Vagina, Cervix And Vulva Procedures With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 37058.36, "minimum": 14700.59, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 37058.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 33124.96 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 34580.1 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31154.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 29226.72 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14700.59 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 30956.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1187.01, "90th_percentile": 1187.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1187.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6063.8, "90th_percentile": 6063.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6063.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7774.46, "90th_percentile": 7774.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7774.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 13799.35, "90th_percentile": 13799.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13799.35, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13503.08, "90th_percentile": 13518.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13503.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 8230.65, "90th_percentile": 8230.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8230.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14544.12, "90th_percentile": 14544.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14544.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 29228.47, "90th_percentile": 29228.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29228.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "745", "type": "MS-DRG" } ], "description": "D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 22679.85, "minimum": 10044.21, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22679.85 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 20272.59 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 21163.14 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 19066.4 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 17886.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10044.21 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 18945.48 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 5345.08, "90th_percentile": 5345.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5345.08, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "744", "type": "MS-DRG" } ], "description": "D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 43241.76, "minimum": 17123.53, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 43241.76 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 38652.05 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 40349.99 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 36352.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 34103.37 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17123.53 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 36121.75 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 19827.85, "90th_percentile": 19827.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19827.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16673.22, "90th_percentile": 16673.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16673.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36983.32, "90th_percentile": 36983.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36983.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6147.56, "90th_percentile": 6147.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6147.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13974.81, "90th_percentile": 15616.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13974.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 10749.43, "90th_percentile": 12276.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10749.43, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13691.27, "90th_percentile": 15156.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13691.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35516.41, "90th_percentile": 35516.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35516.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 36066.93, "90th_percentile": 36066.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36066.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15030.17, "90th_percentile": 15030.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15030.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 32396.55, "90th_percentile": 32396.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32396.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "743", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 26526.22, "minimum": 10845.64, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 26526.22 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 23710.71 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 24752.29 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 22299.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 20920.36 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10845.64 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 22158.52 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 25235.53, "90th_percentile": 186304.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26528.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9928.25, "90th_percentile": 10550.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9933.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 26528.43, "90th_percentile": 29008.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26528.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "10th_percentile": 8583.2, "90th_percentile": 8583.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8583.2, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7206.35, "90th_percentile": 7206.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7206.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22941.85, "90th_percentile": 25871.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 23544.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 6826.2, "90th_percentile": 6826.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6826.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9922.72, "90th_percentile": 10293.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10237.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 57589.61, "90th_percentile": 57589.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57589.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 6887.7, "90th_percentile": 6887.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6887.7, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25441.73, "90th_percentile": 25441.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25441.73, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 6522.99, "90th_percentile": 8066.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6522.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 88352.05, "90th_percentile": 88352.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 88352.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 98977.74, "90th_percentile": 98977.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 98977.74, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 10732.34, "90th_percentile": 10732.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10732.34, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 22559.06, "90th_percentile": 22559.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22559.06, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 6129.17, "90th_percentile": 6129.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6129.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9938.26, "90th_percentile": 15742.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10118.95, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23312.97, "90th_percentile": 27206.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23517.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "10th_percentile": 24295.83, "90th_percentile": 24295.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24295.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 7133.69, "90th_percentile": 8342.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7224.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 20922.11, "90th_percentile": 24531.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20922.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 6833.61, "90th_percentile": 6833.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6833.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10028.26, "90th_percentile": 10730.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10082.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18952.99, "90th_percentile": 24522.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 20922.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "742", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 40424.48, "minimum": 15459.31, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40424.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 36133.8 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37721.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33983.89 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31881.48 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15459.31 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33768.35 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 38783.72, "90th_percentile": 40173.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39465.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12749.75, "90th_percentile": 14695.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14661.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 42710.07, "90th_percentile": 42710.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42710.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 8765.62, "90th_percentile": 8765.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8765.62, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32995.63, "90th_percentile": 38259.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 35718.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 8387.79, "90th_percentile": 33537.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8387.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13369.97, "90th_percentile": 14672.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13494.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 34945.31, "90th_percentile": 36880.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34945.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "10th_percentile": 7551.59, "90th_percentile": 7551.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7551.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 39089.45, "90th_percentile": 39703.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39703.32, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 7133.69, "90th_percentile": 7133.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7133.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13427.92, "90th_percentile": 14668.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13748.86, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33985.75, "90th_percentile": 295645.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35830.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 14193.89, "90th_percentile": 14193.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14193.89, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 72385.0, "90th_percentile": 72385.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72385.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 18682.37, "90th_percentile": 18682.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18682.37, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 33717.23, "90th_percentile": 33717.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33717.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14832.95, "90th_percentile": 14844.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14832.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 28918.22, "90th_percentile": 179608.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33412.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "741", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 30396.93, "minimum": 12285.43, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 30396.93 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 27170.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 28364.15 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 25553.97 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 23973.07 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12285.43 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 25391.89 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27172.56, "90th_percentile": 28642.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27172.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11245.9, "90th_percentile": 11245.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11245.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 8342.71, "90th_percentile": 8342.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8342.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10823.2, "90th_percentile": 11239.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10823.2, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 27978.66, "90th_percentile": 27978.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27978.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11123.12, "90th_percentile": 11123.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11123.12, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 62516.68, "90th_percentile": 62516.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62516.68, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10547.79, "90th_percentile": 10547.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10547.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10938.52, "90th_percentile": 10938.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10938.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 23558.98, "90th_percentile": 23558.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23558.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "740", "type": "MS-DRG" } ], "description": "Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc", "standard_charges": [ { "billing_class": "facility", "maximum": 40238.58, "minimum": 15263.61, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_dollar": 40238.58 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 35967.63 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_dollar": 37547.65 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 33827.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_dollar": 31734.86 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15263.61 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 33613.06 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "10th_percentile": 42291.58, "90th_percentile": 42291.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42291.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13291.21, "90th_percentile": 13315.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13291.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35715.05, "90th_percentile": 234452.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37915.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "10th_percentile": 10711.73, "90th_percentile": 10711.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10711.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14113.67, "90th_percentile": 14970.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14601.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "10th_percentile": 32502.67, "90th_percentile": 32502.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32502.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "10th_percentile": 9675.7, "90th_percentile": 9675.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9675.7, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "10th_percentile": 99329.66, "90th_percentile": 99329.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99329.66, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "10th_percentile": 14135.84, "90th_percentile": 14135.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14135.84, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "10th_percentile": 11123.12, "90th_percentile": 11123.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11123.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12710.41, "90th_percentile": 12710.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12710.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 35618.81, "90th_percentile": 35673.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35618.81, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "10th_percentile": 13705.73, "90th_percentile": 13705.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13705.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 11123.12, "90th_percentile": 11123.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11123.12, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13483.16, "90th_percentile": 13483.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13483.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31484.12, "90th_percentile": 33562.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31484.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "10th_percentile": 10547.79, "90th_percentile": 10547.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10547.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13756.71, "90th_percentile": 15168.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14726.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 31736.61, "90th_percentile": 33401.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31736.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "455", "type": "MS-DRG" } ], "description": "Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "maximum": 91107.98, "minimum": 85143.73, "payers_information": [ { "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_dollar": 91107.98 }, { "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_dollar": 85687.19 }, { "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_dollar": 85143.73 } ], "setting": "inpatient" }, { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "0763", "type": "APC" } ], "description": "Inj, bupivacaine liposome", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28283.0, "90th_percentile": 28283.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28283.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6156.64, "90th_percentile": 6156.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6156.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 48427.91, "90th_percentile": 48427.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48427.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3051.51, "90th_percentile": 3051.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3051.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0764", "type": "APC" } ], "description": "Ketorolac tromethamine inj", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9085.74, "90th_percentile": 49066.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 13441.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6920.97, "90th_percentile": 8556.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6920.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 83095.93, "90th_percentile": 83095.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83095.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1724.9, "90th_percentile": 1724.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1724.9, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7818.43, "90th_percentile": 53216.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 9578.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2455.94, "90th_percentile": 2455.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2455.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6392.41, "90th_percentile": 6392.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6392.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 5682.49, "90th_percentile": 5682.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5682.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1665.42, "90th_percentile": 5061.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1665.42, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1933.07, "90th_percentile": 5569.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 1933.07, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27138.83, "90th_percentile": 27138.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27138.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 13735.88, "90th_percentile": 125238.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32511.59, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1809.99, "90th_percentile": 1809.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1809.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6621.48, "90th_percentile": 29859.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6621.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9891.95, "90th_percentile": 18092.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 13329.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 5751.97, "90th_percentile": 5751.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5751.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17536.92, "90th_percentile": 17536.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17536.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1621.6, "90th_percentile": 4856.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1724.9, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10413.53, "90th_percentile": 10413.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10413.53, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14680.19, "90th_percentile": 24613.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17008.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1635.68, "90th_percentile": 7020.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4360.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9667.27, "90th_percentile": 21494.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 12950.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0792", "type": "APC" } ], "description": "Inj, glycopyrrolate, 0.1 mg", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2032.95, "90th_percentile": 2032.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2032.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18124.79, "90th_percentile": 18124.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18124.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1573.49, "90th_percentile": 1573.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1573.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0794", "type": "APC" } ], "description": "Inj, bumetanide, 0.5 mg", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 61.25, "90th_percentile": 61.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1511", "type": "APC" } ], "description": "New Technology - Level 11 ($901 - $1000)", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 3325.81, "90th_percentile": 3325.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3325.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3123.32, "90th_percentile": 3123.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3123.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2090.55, "90th_percentile": 2090.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2090.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1521", "type": "APC" } ], "description": "New Technology - Level 21 ($1901-$2000)", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5821.65, "90th_percentile": 7859.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5821.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1822.46, "90th_percentile": 1824.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1822.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1480.79, "90th_percentile": 1480.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1480.79, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3205.37, "90th_percentile": 5069.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 3885.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1533.96, "90th_percentile": 1533.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1533.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1517.66, "90th_percentile": 1829.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1827.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2099.16, "90th_percentile": 2856.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2099.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1429.72, "90th_percentile": 1429.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1429.72, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3264.48, "90th_percentile": 3264.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3264.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1659.51, "90th_percentile": 1796.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1659.51, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 5319.1, "90th_percentile": 5889.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5319.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1898.94, "90th_percentile": 1898.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1898.94, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1466.07, "90th_percentile": 1466.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1466.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1502.96, "90th_percentile": 1827.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1827.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5576.83, "90th_percentile": 24528.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5576.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1824.96, "90th_percentile": 1824.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1824.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1466.07, "90th_percentile": 1466.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1466.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10073.82, "90th_percentile": 10073.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10073.82, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6579.24, "90th_percentile": 6732.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6593.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1712.28, "90th_percentile": 1843.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1712.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4369.56, "90th_percentile": 7060.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6701.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1522", "type": "APC" } ], "description": "New Technology - Level 22 ($2001-$2500)", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5081.74, "90th_percentile": 18834.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 7904.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2008.51, "90th_percentile": 4579.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "234", "median_amount": 2103.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 5551.9, "90th_percentile": 14086.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 7030.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2164.97, "90th_percentile": 2164.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2164.97, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1608.02, "90th_percentile": 1608.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1608.02, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2304.71, "90th_percentile": 11514.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "144", "median_amount": 4653.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1532.96, "90th_percentile": 3906.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1532.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1714.51, "90th_percentile": 4580.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "118", "median_amount": 2107.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7539.25, "90th_percentile": 7539.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7539.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1549.69, "90th_percentile": 3977.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 2646.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1334.52, "90th_percentile": 4079.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2231.1, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4490.28, "90th_percentile": 10116.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4490.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1795.37, "90th_percentile": 4219.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 1932.51, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4529.25, "90th_percentile": 4529.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4529.25, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7333.25, "90th_percentile": 30381.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12706.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 4735.59, "90th_percentile": 19839.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18253.84, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 12172.81, "90th_percentile": 12172.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12172.81, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1904.5, "90th_percentile": 4684.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2144.5, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1602.02, "90th_percentile": 4035.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2872.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1783.11, "90th_percentile": 4583.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "140", "median_amount": 2108.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5144.15, "90th_percentile": 20694.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 7926.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2778.04, "90th_percentile": 6057.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4364.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1965.92, "90th_percentile": 3410.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 2105.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 4598.49, "90th_percentile": 4598.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4598.49, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1602.02, "90th_percentile": 3771.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 1602.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1748.54, "90th_percentile": 2719.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1748.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9583.55, "90th_percentile": 9583.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9583.55, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5538.67, "90th_percentile": 17340.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 8017.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1519.16, "90th_percentile": 3661.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 1528.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1698.1, "90th_percentile": 4623.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "130", "median_amount": 2125.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5538.67, "90th_percentile": 17064.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 8017.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1580", "type": "APC" } ], "description": "New Technology - Level 43 ($40,001-$50,000)", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42134.34, "90th_percentile": 42134.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42134.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 42111.78, "90th_percentile": 42111.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42111.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 53735.29, "90th_percentile": 53735.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53735.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 42413.17, "90th_percentile": 42413.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42413.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 55813.91, "90th_percentile": 55813.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55813.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "2040", "type": "APC" } ], "description": "Endo, single, urinary tract", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 27419.67, "90th_percentile": 27419.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27419.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9844.27, "90th_percentile": 9844.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9844.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21328.8, "90th_percentile": 21328.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21328.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3200.66, "90th_percentile": 3200.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3200.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9404.97, "90th_percentile": 9404.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9404.97, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 9842.97, "90th_percentile": 9842.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9842.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 100.06, "90th_percentile": 2651.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 100.06, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2514.51, "90th_percentile": 2514.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2514.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "2044", "type": "APC" } ], "description": "Ret dev, laser, ivc filter", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 28213.91, "90th_percentile": 28213.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28213.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "2045", "type": "APC" } ], "description": "Grft, trnsmurl/trnsvens byps", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31788.37, "90th_percentile": 31788.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31788.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "2050", "type": "APC" } ], "description": "Cath coronary drug-delivery", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14651.73, "90th_percentile": 14651.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14651.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9060.03, "90th_percentile": 9060.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9060.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 460.0, "90th_percentile": 460.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 460.0, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "2051", "type": "APC" } ], "description": "Cath renal denerv radiofreq", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8959.04, "90th_percentile": 8959.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8959.04, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "2616", "type": "APC" } ], "description": "Brachytx, non-str,Yttrium-90", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 62835.47, "90th_percentile": 62835.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62835.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16833.47, "90th_percentile": 27739.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27529.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10969.32, "90th_percentile": 10969.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10969.32, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46498.0, "90th_percentile": 46498.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46498.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27725.7, "90th_percentile": 27725.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27725.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 28143.57, "90th_percentile": 29408.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28143.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 32992.19, "90th_percentile": 32992.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32992.19, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 55788.87, "90th_percentile": 55788.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55788.87, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27435.9, "90th_percentile": 27734.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27725.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 62086.07, "90th_percentile": 62086.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62086.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 35846.32, "90th_percentile": 35846.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35846.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 27372.9, "90th_percentile": 27732.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27732.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27601.75, "90th_percentile": 27601.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27601.75, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 60091.46, "90th_percentile": 60133.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60091.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25251.42, "90th_percentile": 31469.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28002.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 92071.03, "90th_percentile": 92071.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 92071.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5012", "type": "APC" } ], "description": "Clinic Visits and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 101.44, "90th_percentile": 353.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "908", "median_amount": 140.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 84.03, "90th_percentile": 84.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 76.24, "90th_percentile": 122.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2888", "median_amount": 120.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 93.33, "90th_percentile": 320.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "167", "median_amount": 136.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 122.44, "90th_percentile": 125.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "47", "median_amount": 125.16, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 82.17, "90th_percentile": 179.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "199", "median_amount": 116.36, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 88.32, "90th_percentile": 298.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2595", "median_amount": 119.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 76.33, "90th_percentile": 188.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "231", "median_amount": 107.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 96.28, "90th_percentile": 120.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1408", "median_amount": 120.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 103.42, "90th_percentile": 300.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 122.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 46.97, "90th_percentile": 135.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "312", "median_amount": 67.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 68.34, "90th_percentile": 185.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "252", "median_amount": 99.29, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 56.88, "90th_percentile": 441.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 90.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 92.09, "90th_percentile": 239.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1109", "median_amount": 130.4, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 95.12, "90th_percentile": 121.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 97.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 30.53, "90th_percentile": 582.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "78", "median_amount": 176.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 80.24, "90th_percentile": 450.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "206", "median_amount": 145.91, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 104.81, "90th_percentile": 216.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 135.95, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 77.8, "90th_percentile": 122.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "124", "median_amount": 120.13, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 202.15, "90th_percentile": 202.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 202.15, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 79.77, "90th_percentile": 168.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "208", "median_amount": 112.82, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 117.73, "90th_percentile": 206.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2143", "median_amount": 120.34, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 30.68, "90th_percentile": 224.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "790", "median_amount": 41.87, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 21.54, "90th_percentile": 82.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "156", "median_amount": 34.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 110.55, "90th_percentile": 122.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "445", "median_amount": 120.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 36.64, "90th_percentile": 676.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 90.94, "90th_percentile": 203.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 118.53, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 81.55, "90th_percentile": 187.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "419", "median_amount": 112.82, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 51.08, "90th_percentile": 128.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "167", "median_amount": 100.13, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 94.18, "90th_percentile": 261.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 174.66, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 123.62, "90th_percentile": 126.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 126.36, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 99.22, "90th_percentile": 307.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "528", "median_amount": 136.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 75.65, "90th_percentile": 202.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "312", "median_amount": 110.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 95.12, "90th_percentile": 177.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1605", "median_amount": 121.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 99.22, "90th_percentile": 327.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1423", "median_amount": 137.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5021", "type": "APC" } ], "description": "Level 1 Type A ED Visits", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 548.53, "90th_percentile": 548.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 548.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 79.07, "90th_percentile": 83.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 82.17, "90th_percentile": 224.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82.17, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 68.44, "90th_percentile": 513.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 477.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 75.61, "90th_percentile": 78.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 83.9, "90th_percentile": 83.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 77.92, "90th_percentile": 77.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 50.0, "90th_percentile": 216.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67.19, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 92.09, "90th_percentile": 195.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 92.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 656.99, "90th_percentile": 656.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 656.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 82.17, "90th_percentile": 114.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 91.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 83.9, "90th_percentile": 83.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 288.4, "90th_percentile": 492.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 288.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 69.59, "90th_percentile": 146.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 79.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 68.41, "90th_percentile": 68.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 481.07, "90th_percentile": 481.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 481.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 74.93, "90th_percentile": 129.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 84.74, "90th_percentile": 84.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 84.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 483.2, "90th_percentile": 639.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 483.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5022", "type": "APC" } ], "description": "Level 2 Type A ED Visits", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 374.97, "90th_percentile": 916.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "205", "median_amount": 778.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 56.63, "90th_percentile": 187.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 147.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 505.96, "90th_percentile": 833.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 778.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 31.3, "90th_percentile": 149.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53.49, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 91.62, "90th_percentile": 189.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "165", "median_amount": 152.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 347.18, "90th_percentile": 1056.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "451", "median_amount": 783.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 92.67, "90th_percentile": 186.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "200", "median_amount": 145.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10.68, "90th_percentile": 150.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 97.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 544.44, "90th_percentile": 544.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 544.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 131.4, "90th_percentile": 451.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 333.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 75.0, "90th_percentile": 153.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "170", "median_amount": 75.0, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 135.24, "90th_percentile": 135.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 135.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 96.49, "90th_percentile": 223.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "807", "median_amount": 171.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 117.7, "90th_percentile": 119.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 119.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 877.08, "90th_percentile": 1420.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 940.61, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 350.0, "90th_percentile": 989.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "88", "median_amount": 734.16, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 745.36, "90th_percentile": 10614.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 928.48, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 25.9, "90th_percentile": 150.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25.9, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15.11, "90th_percentile": 15.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15.11, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 96.85, "90th_percentile": 199.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "168", "median_amount": 152.42, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28.06, "90th_percentile": 151.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "60", "median_amount": 99.98, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 411.0, "90th_percentile": 1166.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "144", "median_amount": 796.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 131.46, "90th_percentile": 678.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 378.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 150.08, "90th_percentile": 150.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 150.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 40.08, "90th_percentile": 40.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40.08, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 84.0, "90th_percentile": 174.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "282", "median_amount": 152.42, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 121.19, "90th_percentile": 152.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 123.04, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 597.55, "90th_percentile": 1116.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 772.34, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 289.41, "90th_percentile": 1291.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "128", "median_amount": 1070.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 91.84, "90th_percentile": 165.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "172", "median_amount": 144.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27.48, "90th_percentile": 152.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 75.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 480.0, "90th_percentile": 1291.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "257", "median_amount": 1221.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5023", "type": "APC" } ], "description": "Level 3 Type A ED Visits", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 640.0, "90th_percentile": 2255.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "287", "median_amount": 1413.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 224.39, "90th_percentile": 224.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 224.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 150.77, "90th_percentile": 488.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "294", "median_amount": 260.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 1073.74, "90th_percentile": 2343.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 1529.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 156.47, "90th_percentile": 275.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 166.27, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 112.09, "90th_percentile": 615.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "193", "median_amount": 166.73, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 640.0, "90th_percentile": 2050.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "745", "median_amount": 1409.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 114.66, "90th_percentile": 588.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "269", "median_amount": 164.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 136.07, "90th_percentile": 458.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "189", "median_amount": 258.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1633.08, "90th_percentile": 1633.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1633.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 140.1, "90th_percentile": 879.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "91", "median_amount": 578.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 143.26, "90th_percentile": 296.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "281", "median_amount": 150.0, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 220.15, "90th_percentile": 1103.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 761.76, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 120.8, "90th_percentile": 713.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1169", "median_amount": 192.26, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 209.72, "90th_percentile": 472.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 212.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 985.84, "90th_percentile": 2779.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 1690.91, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 742.0, "90th_percentile": 2143.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "137", "median_amount": 1398.81, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 1192.58, "90th_percentile": 2855.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1282.77, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 138.85, "90th_percentile": 556.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 263.85, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 350.0, "90th_percentile": 400.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 350.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 114.39, "90th_percentile": 636.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "280", "median_amount": 166.73, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 139.92, "90th_percentile": 480.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "232", "median_amount": 258.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1002.16, "90th_percentile": 2462.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "224", "median_amount": 1451.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 587.93, "90th_percentile": 1064.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 768.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 161.07, "90th_percentile": 264.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 258.57, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2308.83, "90th_percentile": 2308.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2308.83, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 170.37, "90th_percentile": 485.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 264.22, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 111.52, "90th_percentile": 582.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "442", "median_amount": 166.73, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 211.42, "90th_percentile": 428.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 215.13, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 528.2, "90th_percentile": 2131.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 1339.23, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 600.0, "90th_percentile": 2466.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "188", "median_amount": 2225.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 105.2, "90th_percentile": 603.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "267", "median_amount": 165.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 153.36, "90th_percentile": 465.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "211", "median_amount": 258.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1222.86, "90th_percentile": 2468.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "445", "median_amount": 2332.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5024", "type": "APC" } ], "description": "Level 4 Type A ED Visits", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1876.52, "90th_percentile": 7852.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1000", "median_amount": 3544.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 312.93, "90th_percentile": 768.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 312.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 399.64, "90th_percentile": 2570.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1630", "median_amount": 727.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 2183.85, "90th_percentile": 8302.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "141", "median_amount": 3856.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 334.85, "90th_percentile": 2589.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 638.92, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 158.64, "90th_percentile": 1401.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "417", "median_amount": 625.75, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1747.28, "90th_percentile": 6562.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2862", "median_amount": 3450.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 151.8, "90th_percentile": 1266.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "528", "median_amount": 579.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 389.14, "90th_percentile": 2563.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "752", "median_amount": 708.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1578.16, "90th_percentile": 4008.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 2651.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 348.4, "90th_percentile": 3143.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "302", "median_amount": 1340.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 250.3, "90th_percentile": 1661.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "684", "median_amount": 837.99, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 117.0, "90th_percentile": 4115.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 1474.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 177.65, "90th_percentile": 1459.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2641", "median_amount": 693.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 401.53, "90th_percentile": 2498.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 743.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2229.72, "90th_percentile": 8304.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "106", "median_amount": 4200.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1586.04, "90th_percentile": 7296.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "425", "median_amount": 3437.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 2449.65, "90th_percentile": 6302.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 4441.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 382.09, "90th_percentile": 2512.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "87", "median_amount": 693.85, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 255.66, "90th_percentile": 9235.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4501.25, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 166.73, "90th_percentile": 1270.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "533", "median_amount": 628.4, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 389.14, "90th_percentile": 2477.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1092", "median_amount": 681.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1943.07, "90th_percentile": 7758.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "834", "median_amount": 3673.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 720.0, "90th_percentile": 3465.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "93", "median_amount": 1923.88, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 397.64, "90th_percentile": 2588.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "160", "median_amount": 737.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2640.34, "90th_percentile": 3707.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3381.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 459.94, "90th_percentile": 2534.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 682.26, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 160.32, "90th_percentile": 1304.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1031", "median_amount": 629.21, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 399.25, "90th_percentile": 2187.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "237", "median_amount": 700.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1658.14, "90th_percentile": 6694.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "108", "median_amount": 3260.44, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 640.21, "90th_percentile": 2279.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 640.21, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1188.46, "90th_percentile": 7853.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "631", "median_amount": 3841.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 163.8, "90th_percentile": 1269.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "612", "median_amount": 609.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 376.87, "90th_percentile": 2542.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "951", "median_amount": 720.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2066.91, "90th_percentile": 7974.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1707", "median_amount": 3954.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5025", "type": "APC" } ], "description": "Level 5 Type A ED Visits", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 2857.16, "90th_percentile": 12578.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "353", "median_amount": 5619.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 695.42, "90th_percentile": 2679.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1245", "median_amount": 1981.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 3366.47, "90th_percentile": 13558.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 5873.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 828.82, "90th_percentile": 2452.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 1110.16, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 231.25, "90th_percentile": 2051.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "192", "median_amount": 767.35, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2836.35, "90th_percentile": 12904.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "978", "median_amount": 5558.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 221.28, "90th_percentile": 2161.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "185", "median_amount": 733.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 632.09, "90th_percentile": 2644.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "517", "median_amount": 1286.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5264.82, "90th_percentile": 6423.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5511.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 624.69, "90th_percentile": 4977.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "135", "median_amount": 2060.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 391.15, "90th_percentile": 2555.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "275", "median_amount": 1181.64, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 657.32, "90th_percentile": 5857.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 1929.6, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 246.77, "90th_percentile": 2151.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1030", "median_amount": 852.3, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 700.18, "90th_percentile": 2525.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 878.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3596.18, "90th_percentile": 17601.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 6695.17, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 2758.91, "90th_percentile": 15791.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "138", "median_amount": 5258.45, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 22865.96, "90th_percentile": 22865.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22865.96, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 590.99, "90th_percentile": 2487.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 1042.76, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13041.43, "90th_percentile": 13041.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13041.43, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 213.03, "90th_percentile": 1858.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "229", "median_amount": 763.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 650.11, "90th_percentile": 2593.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "793", "median_amount": 1254.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2849.7, "90th_percentile": 12491.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "303", "median_amount": 5426.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 1017.34, "90th_percentile": 6630.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 3174.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 673.44, "90th_percentile": 2704.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "107", "median_amount": 2079.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12845.68, "90th_percentile": 12845.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12845.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 574.74, "90th_percentile": 2644.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "55", "median_amount": 1201.51, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 231.25, "90th_percentile": 2059.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "475", "median_amount": 779.62, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 544.76, "90th_percentile": 2463.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "153", "median_amount": 1512.99, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2809.13, "90th_percentile": 18770.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "50", "median_amount": 5274.52, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2451.12, "90th_percentile": 14512.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "226", "median_amount": 5533.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 216.47, "90th_percentile": 1983.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "245", "median_amount": 770.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 579.56, "90th_percentile": 2635.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "620", "median_amount": 1358.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3031.96, "90th_percentile": 12984.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "574", "median_amount": 6193.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5041", "type": "APC" } ], "description": "Critical Care", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5736.53, "90th_percentile": 5736.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5736.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1482.9, "90th_percentile": 5278.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2372.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10849.17, "90th_percentile": 14347.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10849.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2813.3, "90th_percentile": 11345.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2813.3, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1577.44, "90th_percentile": 1577.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1577.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 2819.17, "90th_percentile": 2819.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2819.17, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2133.72, "90th_percentile": 2133.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2133.72, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1512.35, "90th_percentile": 1512.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1512.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2770.23, "90th_percentile": 2770.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2770.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20686.32, "90th_percentile": 20686.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20686.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5045", "type": "APC" } ], "description": "Trauma Response with Critical Care", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18842.37, "90th_percentile": 18842.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18842.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2333.8, "90th_percentile": 2333.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2333.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3669.11, "90th_percentile": 3669.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3669.11, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3633.46, "90th_percentile": 3633.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3633.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31835.94, "90th_percentile": 31835.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31835.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5051", "type": "APC" } ], "description": "Level 1 Skin Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 848.52, "90th_percentile": 2216.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 1422.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 146.35, "90th_percentile": 261.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 185.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 1041.48, "90th_percentile": 1339.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1333.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 31.3, "90th_percentile": 31.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31.3, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 276.87, "90th_percentile": 461.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 384.46, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 348.15, "90th_percentile": 2919.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "69", "median_amount": 1601.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 223.2, "90th_percentile": 436.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 309.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 148.44, "90th_percentile": 361.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 176.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 201.08, "90th_percentile": 916.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 776.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 75.0, "90th_percentile": 398.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 225.21, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 572.04, "90th_percentile": 572.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 572.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 261.4, "90th_percentile": 462.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 362.53, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 269.41, "90th_percentile": 269.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 269.41, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2042.65, "90th_percentile": 2042.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2042.65, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1063.23, "90th_percentile": 2409.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 1265.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 233.25, "90th_percentile": 412.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 378.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 136.07, "90th_percentile": 263.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 225.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1151.33, "90th_percentile": 2077.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 1387.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 536.68, "90th_percentile": 979.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 536.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 170.37, "90th_percentile": 260.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 170.37, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 224.3, "90th_percentile": 412.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 284.05, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 126.35, "90th_percentile": 215.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 215.13, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 778.1, "90th_percentile": 1922.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1535.69, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 307.64, "90th_percentile": 2466.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 1325.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 221.19, "90th_percentile": 405.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 379.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 151.86, "90th_percentile": 299.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 181.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 842.8, "90th_percentile": 3098.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 1333.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5052", "type": "APC" } ], "description": "Level 2 Skin Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 757.77, "90th_percentile": 1768.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "93", "median_amount": 919.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 298.48, "90th_percentile": 374.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "483", "median_amount": 373.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 895.59, "90th_percentile": 16656.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1063.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 287.99, "90th_percentile": 971.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 299.49, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1255.5, "90th_percentile": 2919.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "210", "median_amount": 1395.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 275.58, "90th_percentile": 644.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 286.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 298.48, "90th_percentile": 373.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "310", "median_amount": 348.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 439.43, "90th_percentile": 796.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 439.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 258.18, "90th_percentile": 717.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 416.49, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 251.1, "90th_percentile": 849.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 502.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 335.63, "90th_percentile": 785.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "162", "median_amount": 335.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 301.47, "90th_percentile": 381.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 301.47, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1156.46, "90th_percentile": 2792.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 1185.16, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 908.15, "90th_percentile": 1931.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 1034.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 335.71, "90th_percentile": 362.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 362.37, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 299.49, "90th_percentile": 599.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 299.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 298.48, "90th_percentile": 374.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "461", "median_amount": 373.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 706.62, "90th_percentile": 1889.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "91", "median_amount": 906.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 489.65, "90th_percentile": 1052.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 495.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 373.1, "90th_percentile": 446.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 373.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 287.99, "90th_percentile": 700.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 299.49, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 295.46, "90th_percentile": 326.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "76", "median_amount": 310.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6417.89, "90th_percentile": 6417.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6417.89, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 898.38, "90th_percentile": 2889.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 898.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 273.1, "90th_percentile": 424.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 284.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 89.33, "90th_percentile": 382.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "205", "median_amount": 376.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 812.44, "90th_percentile": 1221.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "131", "median_amount": 898.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5053", "type": "APC" } ], "description": "Level 3 Skin Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 991.25, "90th_percentile": 13655.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1663.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 457.31, "90th_percentile": 1210.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 572.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 900.25, "90th_percentile": 900.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 900.25, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 526.71, "90th_percentile": 526.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 526.71, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2170.22, "90th_percentile": 3943.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 3614.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2795.88, "90th_percentile": 2795.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2795.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 457.31, "90th_percentile": 1273.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 571.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 641.88, "90th_percentile": 641.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 641.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 258.18, "90th_percentile": 433.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 289.16, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 335.63, "90th_percentile": 1346.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 503.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3365.07, "90th_percentile": 10459.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3365.07, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 299.49, "90th_percentile": 598.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 299.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 527.53, "90th_percentile": 759.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 571.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7148.7, "90th_percentile": 7722.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7148.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 572.48, "90th_percentile": 759.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 758.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2030.1, "90th_percentile": 2030.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2030.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2364.23, "90th_percentile": 2364.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2364.23, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2584.01, "90th_percentile": 2584.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2584.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 284.0, "90th_percentile": 426.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 284.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 359.07, "90th_percentile": 866.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 595.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1212.04, "90th_percentile": 7174.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 2088.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5054", "type": "APC" } ], "description": "Level 4 Skin Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16276.37, "90th_percentile": 33918.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16276.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1277.39, "90th_percentile": 1712.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 1709.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9185.06, "90th_percentile": 23456.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9773.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1480.66, "90th_percentile": 1708.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 1678.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 8428.71, "90th_percentile": 8428.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8428.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1674.22, "90th_percentile": 1982.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1982.79, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31163.91, "90th_percentile": 31163.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31163.91, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 6898.94, "90th_percentile": 11926.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6901.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3096.53, "90th_percentile": 3096.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3096.53, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1708.21, "90th_percentile": 1987.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 1894.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1708.21, "90th_percentile": 3966.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1708.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1839.88, "90th_percentile": 1839.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1839.88, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13025.97, "90th_percentile": 21191.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13025.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1536.29, "90th_percentile": 1725.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 1725.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 16206.71, "90th_percentile": 18562.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17003.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5055", "type": "APC" } ], "description": "Level 5 Skin Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16655.0, "90th_percentile": 16655.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16655.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2061.93, "90th_percentile": 2061.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2061.93, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20301.07, "90th_percentile": 20301.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20301.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3452.97, "90th_percentile": 3452.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3452.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20239.02, "90th_percentile": 20239.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20239.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5061", "type": "APC" } ], "description": "Hyperbaric Oxygen", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5179.66, "90th_percentile": 5316.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 5179.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35.0, "90th_percentile": 515.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "236", "median_amount": 515.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4510.01, "90th_percentile": 4647.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "116", "median_amount": 4647.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 494.31, "90th_percentile": 515.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 494.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 5365.22, "90th_percentile": 5365.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 5365.22, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 515.09, "90th_percentile": 515.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 515.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4961.82, "90th_percentile": 5244.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "94", "median_amount": 5098.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 113.55, "90th_percentile": 520.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "86", "median_amount": 520.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5066.7, "90th_percentile": 5942.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 5066.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5071", "type": "APC" } ], "description": "Level 1 Excision/ Biopsy/ Incision and Drainage", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1000.0, "90th_percentile": 5937.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 4015.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 314.04, "90th_percentile": 664.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 652.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 4038.21, "90th_percentile": 6673.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4273.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 505.19, "90th_percentile": 505.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 505.19, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 468.92, "90th_percentile": 468.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 468.92, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1979.21, "90th_percentile": 8411.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "105", "median_amount": 3714.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 461.03, "90th_percentile": 1542.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 701.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 353.24, "90th_percentile": 664.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 632.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 242.72, "90th_percentile": 3189.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 1820.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 415.34, "90th_percentile": 1822.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1247.66, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 362.53, "90th_percentile": 539.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 539.94, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 530.89, "90th_percentile": 530.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 530.89, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4232.97, "90th_percentile": 8838.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5493.04, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 3233.42, "90th_percentile": 7486.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 4283.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 7672.83, "90th_percentile": 7672.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7672.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 383.63, "90th_percentile": 639.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 394.39, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 481.79, "90th_percentile": 1206.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 816.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 265.04, "90th_percentile": 667.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 646.04, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1671.08, "90th_percentile": 6580.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 3505.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 795.07, "90th_percentile": 3915.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1068.24, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 323.84, "90th_percentile": 663.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 661.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 366.95, "90th_percentile": 481.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 481.79, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 546.66, "90th_percentile": 690.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 546.66, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4941.88, "90th_percentile": 4941.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4941.88, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1576.36, "90th_percentile": 4899.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 3354.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 306.75, "90th_percentile": 1269.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 456.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 369.61, "90th_percentile": 671.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 640.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1580.22, "90th_percentile": 6468.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "64", "median_amount": 3415.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5072", "type": "APC" } ], "description": "Level 2 Excision/ Biopsy/ Incision and Drainage", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3373.75, "90th_percentile": 12249.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "136", "median_amount": 6338.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1210.44, "90th_percentile": 1606.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "255", "median_amount": 1514.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 4223.08, "90th_percentile": 10374.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 5107.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 1279.58, "90th_percentile": 1579.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1279.58, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1257.8, "90th_percentile": 4270.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1801.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5344.49, "90th_percentile": 12690.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "372", "median_amount": 8443.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 532.27, "90th_percentile": 2091.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 1236.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1209.25, "90th_percentile": 2138.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "136", "median_amount": 1513.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 400.0, "90th_percentile": 5021.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "65", "median_amount": 2148.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 581.01, "90th_percentile": 2135.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 1214.43, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2892.24, "90th_percentile": 2892.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2892.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1142.36, "90th_percentile": 1896.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "58", "median_amount": 1448.17, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1222.55, "90th_percentile": 1222.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1222.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2563.57, "90th_percentile": 23428.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 6741.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 4021.48, "90th_percentile": 14258.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "70", "median_amount": 7035.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 10497.28, "90th_percentile": 10497.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10497.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 993.93, "90th_percentile": 2681.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1131.93, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 175.0, "90th_percentile": 175.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 175.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 700.87, "90th_percentile": 1328.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1292.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1076.41, "90th_percentile": 1936.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "165", "median_amount": 1513.05, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3480.88, "90th_percentile": 12386.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "150", "median_amount": 6047.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 100.0, "90th_percentile": 5709.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 3831.69, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1179.84, "90th_percentile": 1520.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 1519.24, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11794.02, "90th_percentile": 11794.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11794.02, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 1516.55, "90th_percentile": 1516.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1516.55, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 952.52, "90th_percentile": 1692.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 1292.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1258.86, "90th_percentile": 1580.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1258.86, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5080.69, "90th_percentile": 9714.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5080.69, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3499.69, "90th_percentile": 11708.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "121", "median_amount": 6120.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 903.25, "90th_percentile": 1726.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1225.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1132.29, "90th_percentile": 1536.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "141", "median_amount": 1528.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3407.66, "90th_percentile": 10772.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "226", "median_amount": 5626.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5073", "type": "APC" } ], "description": "Level 3 Excision/ Biopsy/ Incision and Drainage", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8054.4, "90th_percentile": 26113.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 11862.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2329.07, "90th_percentile": 3345.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 2674.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 13880.14, "90th_percentile": 20105.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17645.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1989.7, "90th_percentile": 1989.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1989.7, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8852.81, "90th_percentile": 16655.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 10271.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1619.35, "90th_percentile": 1619.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1619.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2285.6, "90th_percentile": 2716.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 2530.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2495.81, "90th_percentile": 22762.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5083.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 7630.92, "90th_percentile": 7630.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7630.92, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 211.05, "90th_percentile": 211.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 211.05, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1855.63, "90th_percentile": 2576.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 2343.87, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2044.74, "90th_percentile": 2044.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2044.74, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 13930.3, "90th_percentile": 19695.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19239.3, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 2177.25, "90th_percentile": 2177.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2177.25, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 2064.01, "90th_percentile": 3109.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2069.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2246.55, "90th_percentile": 2682.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 2672.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10112.06, "90th_percentile": 29327.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 20037.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 6627.23, "90th_percentile": 14392.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6627.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2339.5, "90th_percentile": 2679.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2339.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1655.8, "90th_percentile": 2146.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1655.8, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2223.69, "90th_percentile": 2223.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2223.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 46719.08, "90th_percentile": 46719.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46719.08, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9262.02, "90th_percentile": 19640.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 12055.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2159.55, "90th_percentile": 2705.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 2699.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9446.72, "90th_percentile": 21475.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 14351.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5091", "type": "APC" } ], "description": "Level 1 Breast/Lymphatic Surgery and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17713.03, "90th_percentile": 32717.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 21479.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3578.86, "90th_percentile": 6453.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 3583.43, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 19296.74, "90th_percentile": 38533.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20877.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2603.29, "90th_percentile": 2603.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2603.29, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3856.26, "90th_percentile": 3856.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3856.26, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15113.31, "90th_percentile": 28330.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "58", "median_amount": 17546.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 5664.05, "90th_percentile": 5664.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5664.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3272.14, "90th_percentile": 6096.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 5786.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 10187.23, "90th_percentile": 17877.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 15449.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 5128.5, "90th_percentile": 9329.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5128.5, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 3175.65, "90th_percentile": 8045.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5045.76, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 25353.35, "90th_percentile": 58398.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41328.93, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 19385.72, "90th_percentile": 33373.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 27414.66, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 3464.0, "90th_percentile": 3464.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3464.0, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 4352.89, "90th_percentile": 4352.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4352.89, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3128.14, "90th_percentile": 6100.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 3585.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18230.22, "90th_percentile": 39003.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 22397.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 9692.12, "90th_percentile": 19406.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9692.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 9129.58, "90th_percentile": 9129.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9129.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1292.22, "90th_percentile": 1292.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1292.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15385.75, "90th_percentile": 22225.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 21497.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 5982.8, "90th_percentile": 5982.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5982.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3428.67, "90th_percentile": 7529.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 3619.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17800.03, "90th_percentile": 23420.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 20392.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5092", "type": "APC" } ], "description": "Level 2 Breast/Lymphatic Surgery and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 28457.02, "90th_percentile": 41704.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28457.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6094.99, "90th_percentile": 8248.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6479.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 29657.06, "90th_percentile": 29657.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29657.06, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30954.8, "90th_percentile": 50288.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 41134.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2055.1, "90th_percentile": 2055.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2055.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5261.21, "90th_percentile": 8717.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6096.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 18300.81, "90th_percentile": 18300.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18300.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 6498.68, "90th_percentile": 11661.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6498.68, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2407.22, "90th_percentile": 10280.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6590.31, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 93350.34, "90th_percentile": 93350.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 93350.34, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 32650.46, "90th_percentile": 80198.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50952.49, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 7201.21, "90th_percentile": 7201.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7201.21, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6098.51, "90th_percentile": 10583.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8655.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 30813.92, "90th_percentile": 30813.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30813.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 27163.67, "90th_percentile": 27163.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27163.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 16909.12, "90th_percentile": 16909.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16909.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2147.61, "90th_percentile": 9172.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2148.71, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21473.87, "90th_percentile": 24550.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22711.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2098.52, "90th_percentile": 5000.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2098.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8106.06, "90th_percentile": 8106.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8106.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10773.4, "90th_percentile": 22970.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 21254.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5093", "type": "APC" } ], "description": "Level 3 Breast/Lymphatic Surgery and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 38216.0, "90th_percentile": 38216.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38216.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10476.22, "90th_percentile": 10476.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10476.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 22827.82, "90th_percentile": 22827.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22827.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5094", "type": "APC" } ], "description": "Level 4 Breast/Lymphatic Surgery and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 72212.04, "90th_percentile": 72212.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72212.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63166.91, "90th_percentile": 69020.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65015.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 118098.63, "90th_percentile": 118098.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 118098.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 110138.23, "90th_percentile": 110138.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110138.23, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 74864.37, "90th_percentile": 102638.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74864.37, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 64199.27, "90th_percentile": 64199.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64199.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 26256.58, "90th_percentile": 26256.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26256.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17919.92, "90th_percentile": 17919.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17919.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 23710.73, "90th_percentile": 29410.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27099.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5101", "type": "APC" } ], "description": "Level 1 Strapping and Cast Application", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 592.57, "90th_percentile": 2428.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 608.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 141.46, "90th_percentile": 221.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "115", "median_amount": 148.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 215.64, "90th_percentile": 215.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 215.64, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 923.0, "90th_percentile": 2691.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "71", "median_amount": 923.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 243.29, "90th_percentile": 243.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 243.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 117.88, "90th_percentile": 211.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 176.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 50.98, "90th_percentile": 50.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 163.99, "90th_percentile": 260.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 170.53, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 147.8, "90th_percentile": 284.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 147.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 805.78, "90th_percentile": 805.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 805.78, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 805.78, "90th_percentile": 1930.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 805.78, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 2767.42, "90th_percentile": 2767.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2767.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 110.36, "90th_percentile": 110.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110.36, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 140.87, "90th_percentile": 254.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 152.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 103.25, "90th_percentile": 221.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "103", "median_amount": 103.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 539.96, "90th_percentile": 1199.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 1199.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 321.2, "90th_percentile": 647.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 321.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 147.35, "90th_percentile": 221.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 221.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 131.88, "90th_percentile": 285.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 152.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 122.6, "90th_percentile": 157.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 122.6, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 594.41, "90th_percentile": 2332.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 594.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 119.06, "90th_percentile": 227.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 151.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 579.64, "90th_percentile": 2335.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 579.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5102", "type": "APC" } ], "description": "Level 2 Strapping and Cast Application", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1119.95, "90th_percentile": 1119.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1119.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 198.41, "90th_percentile": 218.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 218.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 766.8, "90th_percentile": 766.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 766.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 142.12, "90th_percentile": 147.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 147.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1459.05, "90th_percentile": 1459.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1459.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 198.41, "90th_percentile": 253.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 248.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 120.25, "90th_percentile": 120.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 120.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1337.64, "90th_percentile": 1337.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1337.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5111", "type": "APC" } ], "description": "Level 1 Musculoskeletal Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1556.07, "90th_percentile": 5356.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2340.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 783.57, "90th_percentile": 1616.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 1081.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 524.02, "90th_percentile": 524.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 524.02, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 585.23, "90th_percentile": 585.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 585.23, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1558.62, "90th_percentile": 5571.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 3714.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 560.01, "90th_percentile": 560.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 560.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 885.5, "90th_percentile": 2080.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1072.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2061.42, "90th_percentile": 2061.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2061.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 859.46, "90th_percentile": 859.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 859.46, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 655.86, "90th_percentile": 1550.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 655.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2523.54, "90th_percentile": 2523.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2523.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 474.44, "90th_percentile": 474.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 474.44, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1214.92, "90th_percentile": 1214.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1214.92, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1038.38, "90th_percentile": 1507.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 1125.98, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3287.79, "90th_percentile": 3287.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3287.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2338.91, "90th_percentile": 2338.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2338.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 595.6, "90th_percentile": 595.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 595.6, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 564.76, "90th_percentile": 564.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 564.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27657.13, "90th_percentile": 30094.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27657.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 809.94, "90th_percentile": 809.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 809.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 922.39, "90th_percentile": 922.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 922.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2332.0, "90th_percentile": 13217.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2486.5, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5112", "type": "APC" } ], "description": "Level 2 Musculoskeletal Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5972.51, "90th_percentile": 16822.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8085.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1386.73, "90th_percentile": 1666.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 1497.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2957.1, "90th_percentile": 9206.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 4959.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1195.91, "90th_percentile": 4622.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1494.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1598.91, "90th_percentile": 3874.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1598.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1894.66, "90th_percentile": 1894.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1894.66, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 850.65, "90th_percentile": 3447.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2068.69, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3348.83, "90th_percentile": 6404.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3450.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 3202.64, "90th_percentile": 17688.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3202.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1400.03, "90th_percentile": 1400.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1400.03, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 2069.12, "90th_percentile": 2069.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2069.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1313.77, "90th_percentile": 1504.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 1497.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2756.22, "90th_percentile": 9728.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 3676.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 1675.97, "90th_percentile": 3412.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1709.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1602.07, "90th_percentile": 1602.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1602.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 1494.53, "90th_percentile": 1494.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1494.53, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1406.99, "90th_percentile": 2168.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1406.99, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1243.44, "90th_percentile": 1243.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1243.44, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5279.04, "90th_percentile": 8837.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5279.04, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3444.58, "90th_percentile": 8474.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5604.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2223.27, "90th_percentile": 2223.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2223.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1284.6, "90th_percentile": 1516.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 1510.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2171.59, "90th_percentile": 7723.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 3024.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5113", "type": "APC" } ], "description": "Level 3 Musculoskeletal Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1618.28, "90th_percentile": 43695.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3245.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2423.96, "90th_percentile": 3199.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 2886.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 5908.97, "90th_percentile": 5908.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5908.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 3151.15, "90th_percentile": 3151.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3151.15, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1547.86, "90th_percentile": 1547.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1547.86, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3562.81, "90th_percentile": 17546.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 5056.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2726.15, "90th_percentile": 3202.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3029.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24408.5, "90th_percentile": 24408.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24408.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1670.45, "90th_percentile": 1760.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1670.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1494.48, "90th_percentile": 3709.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1494.48, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1734.67, "90th_percentile": 4305.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 2463.06, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 3452.25, "90th_percentile": 32741.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22474.27, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1547.86, "90th_percentile": 2197.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1547.86, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2539.95, "90th_percentile": 8360.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 2882.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 201.58, "90th_percentile": 23260.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 3109.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 26336.52, "90th_percentile": 26336.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26336.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1547.86, "90th_percentile": 5268.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1547.86, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2520.92, "90th_percentile": 2520.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2520.92, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4348.46, "90th_percentile": 4348.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4348.46, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3330.28, "90th_percentile": 18106.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3336.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2653.56, "90th_percentile": 9286.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3060.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3175.17, "90th_percentile": 20433.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 3330.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5114", "type": "APC" } ], "description": "Level 4 Musculoskeletal Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9540.61, "90th_percentile": 46670.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 23968.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5336.89, "90th_percentile": 9744.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 6676.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 19838.5, "90th_percentile": 54249.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24075.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5932.9, "90th_percentile": 5932.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5932.9, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28443.91, "90th_percentile": 39967.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "103", "median_amount": 31685.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 4318.12, "90th_percentile": 6277.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4568.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5502.27, "90th_percentile": 8026.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 6677.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 12582.99, "90th_percentile": 26685.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13752.33, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 5653.58, "90th_percentile": 7055.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5653.58, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11137.67, "90th_percentile": 11137.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11137.67, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 5145.18, "90th_percentile": 7794.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 5596.89, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6655.82, "90th_percentile": 6655.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6655.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 49853.1, "90th_percentile": 49853.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49853.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 22040.07, "90th_percentile": 61473.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30359.24, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 6257.26, "90th_percentile": 12260.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6576.01, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 4774.33, "90th_percentile": 7839.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5053.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6220.31, "90th_percentile": 6844.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 6680.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19205.53, "90th_percentile": 42462.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 29686.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 22885.91, "90th_percentile": 75132.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22906.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 6474.59, "90th_percentile": 26500.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6843.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 244.41, "90th_percentile": 244.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 244.41, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4774.33, "90th_percentile": 7306.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 4997.6, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5550.37, "90th_percentile": 5550.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5550.37, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27491.85, "90th_percentile": 27491.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27491.85, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17101.44, "90th_percentile": 27359.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 21482.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 4554.56, "90th_percentile": 5762.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4681.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5523.87, "90th_percentile": 9700.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 6743.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 16692.7, "90th_percentile": 25144.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 20432.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5115", "type": "APC" } ], "description": "Level 5 Musculoskeletal Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30333.52, "90th_percentile": 57376.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 42531.24, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11765.17, "90th_percentile": 12482.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "193", "median_amount": 12190.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 30938.85, "90th_percentile": 65537.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37549.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 13672.05, "90th_percentile": 13672.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13672.05, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11481.84, "90th_percentile": 12090.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12046.67, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31685.0, "90th_percentile": 53758.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "129", "median_amount": 49362.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 11425.44, "90th_percentile": 13453.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11527.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9778.52, "90th_percentile": 12426.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "85", "median_amount": 12186.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31685.0, "90th_percentile": 31685.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31685.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 18152.84, "90th_percentile": 42893.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 25651.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3355.44, "90th_percentile": 13636.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6724.76, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27228.99, "90th_percentile": 27228.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27228.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 12706.34, "90th_percentile": 15436.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 13402.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 45994.56, "90th_percentile": 97240.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51903.01, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 39063.97, "90th_percentile": 73045.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52746.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 52224.82, "90th_percentile": 52224.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52224.82, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 11804.67, "90th_percentile": 19089.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12429.54, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 13826.5, "90th_percentile": 13826.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13826.5, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11615.41, "90th_percentile": 12491.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "84", "median_amount": 12191.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31652.83, "90th_percentile": 67924.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 39081.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 22716.61, "90th_percentile": 26726.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25370.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 11721.27, "90th_percentile": 12214.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 11919.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11959.59, "90th_percentile": 12791.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 12099.95, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10154.57, "90th_percentile": 10154.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10154.57, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 56036.63, "90th_percentile": 91216.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60099.04, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 23368.53, "90th_percentile": 29721.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 27477.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 11267.19, "90th_percentile": 12624.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11285.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9610.33, "90th_percentile": 12336.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "64", "median_amount": 12303.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24805.66, "90th_percentile": 31925.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "73", "median_amount": 28028.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5116", "type": "APC" } ], "description": "Level 6 Musculoskeletal Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 53882.03, "90th_percentile": 71078.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53882.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16603.52, "90th_percentile": 17541.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 17369.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33542.0, "90th_percentile": 113964.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 53757.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17143.28, "90th_percentile": 17373.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17223.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 22187.68, "90th_percentile": 22257.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22187.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 71826.42, "90th_percentile": 71826.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 71826.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 6429.94, "90th_percentile": 6429.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6429.94, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 10107.68, "90th_percentile": 10107.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10107.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16597.22, "90th_percentile": 17539.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 17184.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 51357.6, "90th_percentile": 51357.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51357.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 30002.95, "90th_percentile": 30002.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30002.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 17369.6, "90th_percentile": 18688.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17532.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14445.88, "90th_percentile": 14445.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14445.88, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 14541.93, "90th_percentile": 14541.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14541.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6926.89, "90th_percentile": 17538.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 16770.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19566.97, "90th_percentile": 51608.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43685.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5151", "type": "APC" } ], "description": "Level 1 Airway Endoscopy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 302.54, "90th_percentile": 394.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 302.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1017.0, "90th_percentile": 15084.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1017.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 181.9, "90th_percentile": 302.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 301.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 827.84, "90th_percentile": 827.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 827.84, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 301.64, "90th_percentile": 301.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 301.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 104.31, "90th_percentile": 395.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 104.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 116.39, "90th_percentile": 117.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 116.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 301.64, "90th_percentile": 301.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 301.64, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 267.74, "90th_percentile": 267.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 267.74, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 638.68, "90th_percentile": 638.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 638.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 82.61, "90th_percentile": 82.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 243.73, "90th_percentile": 304.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 297.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 638.67, "90th_percentile": 638.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 638.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5153", "type": "APC" } ], "description": "Level 3 Airway Endoscopy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8065.91, "90th_percentile": 14274.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8678.62, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1288.31, "90th_percentile": 1617.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 1517.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 8959.08, "90th_percentile": 8959.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8959.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 148.98, "90th_percentile": 148.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 148.98, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8002.88, "90th_percentile": 9773.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 9206.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1793.58, "90th_percentile": 1793.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1793.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1517.28, "90th_percentile": 1643.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1616.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1110.22, "90th_percentile": 6732.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4271.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1347.38, "90th_percentile": 1347.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1347.38, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 163.58, "90th_percentile": 2994.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 176.73, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8355.16, "90th_percentile": 8355.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8355.16, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 8944.99, "90th_percentile": 11249.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9210.49, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1159.58, "90th_percentile": 1625.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 1288.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6285.2, "90th_percentile": 17457.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 7686.42, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 3782.19, "90th_percentile": 4745.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3782.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1611.08, "90th_percentile": 1611.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1611.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 135.75, "90th_percentile": 135.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 135.75, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 1700.9, "90th_percentile": 1700.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1700.9, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5386.7, "90th_percentile": 8932.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7789.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2268.19, "90th_percentile": 2268.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2268.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1301.19, "90th_percentile": 1632.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 1626.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7851.51, "90th_percentile": 9609.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 8526.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5154", "type": "APC" } ], "description": "Level 4 Airway Endoscopy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 14070.56, "90th_percentile": 36040.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 17986.52, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3337.87, "90th_percentile": 7947.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 3451.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 18781.48, "90th_percentile": 18781.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18781.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3281.09, "90th_percentile": 5415.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3281.09, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15689.0, "90th_percentile": 27380.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 16655.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1697.07, "90th_percentile": 1697.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1697.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3055.92, "90th_percentile": 6471.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 3340.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 4804.1, "90th_percentile": 7189.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7028.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3769.27, "90th_percentile": 3769.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3769.27, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12341.48, "90th_percentile": 12341.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12341.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 3677.09, "90th_percentile": 4422.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3677.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 19437.45, "90th_percentile": 32209.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21186.25, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2754.42, "90th_percentile": 6133.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 3175.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11368.91, "90th_percentile": 21070.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17282.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 12432.25, "90th_percentile": 12432.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12432.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 3090.23, "90th_percentile": 10907.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6148.14, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3281.09, "90th_percentile": 3281.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3281.09, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21332.48, "90th_percentile": 21332.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21332.48, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11516.2, "90th_percentile": 31961.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19501.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1718.37, "90th_percentile": 1718.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1718.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2781.97, "90th_percentile": 6535.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 3477.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11929.29, "90th_percentile": 21498.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16478.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5155", "type": "APC" } ], "description": "Level 5 Airway Endoscopy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 30666.03, "90th_percentile": 70378.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30666.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6101.81, "90th_percentile": 6471.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6469.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 26086.58, "90th_percentile": 26086.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26086.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7161.27, "90th_percentile": 7161.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7161.27, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31915.86, "90th_percentile": 50069.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37411.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 6105.27, "90th_percentile": 6105.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6105.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6470.69, "90th_percentile": 7831.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6470.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9454.65, "90th_percentile": 9454.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9454.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 14760.56, "90th_percentile": 14760.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14760.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 8595.51, "90th_percentile": 9382.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8595.51, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 61834.88, "90th_percentile": 61834.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61834.88, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 27543.17, "90th_percentile": 27543.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27543.17, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 6596.42, "90th_percentile": 6596.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6596.42, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 8314.63, "90th_percentile": 8314.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8314.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6033.29, "90th_percentile": 6473.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6469.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 56619.97, "90th_percentile": 56619.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 56619.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19143.24, "90th_percentile": 20334.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19143.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2445.73, "90th_percentile": 2445.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2445.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6555.52, "90th_percentile": 6555.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6555.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17951.37, "90th_percentile": 21470.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20417.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5161", "type": "APC" } ], "description": "Level 1 ENT Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 599.12, "90th_percentile": 599.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 599.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1931.56, "90th_percentile": 1931.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1931.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1420.07, "90th_percentile": 1420.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1420.07, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 221.28, "90th_percentile": 221.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 221.28, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5218.63, "90th_percentile": 5218.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5218.63, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 132.07, "90th_percentile": 132.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 132.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15503.21, "90th_percentile": 15503.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15503.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5162", "type": "APC" } ], "description": "Level 2 ENT Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13996.93, "90th_percentile": 13996.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13996.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2423.55, "90th_percentile": 2423.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2423.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21172.75, "90th_percentile": 21172.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21172.75, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 14407.7, "90th_percentile": 14407.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14407.7, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12640.8, "90th_percentile": 12640.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12640.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 985.92, "90th_percentile": 985.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 985.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 16570.24, "90th_percentile": 16570.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16570.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5163", "type": "APC" } ], "description": "Level 3 ENT Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9444.68, "90th_percentile": 11994.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9444.68, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7084.8, "90th_percentile": 9206.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7084.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 3649.62, "90th_percentile": 3649.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3649.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1106.63, "90th_percentile": 1106.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1106.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2970.88, "90th_percentile": 2970.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2970.88, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1318.81, "90th_percentile": 1318.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1318.81, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7406.19, "90th_percentile": 8171.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7406.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15641.63, "90th_percentile": 20243.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15641.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5164", "type": "APC" } ], "description": "Level 4 ENT Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13301.97, "90th_percentile": 24089.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 18848.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2422.81, "90th_percentile": 5946.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3030.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 15668.02, "90th_percentile": 20681.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19197.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1796.61, "90th_percentile": 5834.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1796.61, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6906.0, "90th_percentile": 21970.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 14505.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2798.75, "90th_percentile": 2798.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2798.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3029.01, "90th_percentile": 4203.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3040.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 11834.67, "90th_percentile": 14098.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11834.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3846.06, "90th_percentile": 3846.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3846.06, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15265.94, "90th_percentile": 15265.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15265.94, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2187.29, "90th_percentile": 5560.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2893.62, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 22166.54, "90th_percentile": 22166.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22166.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 16006.14, "90th_percentile": 34853.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24667.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 2925.9, "90th_percentile": 2925.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2925.9, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3030.51, "90th_percentile": 3042.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3037.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21216.67, "90th_percentile": 22678.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21216.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 6063.79, "90th_percentile": 6063.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6063.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 3034.71, "90th_percentile": 3034.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3034.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2860.98, "90th_percentile": 2860.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2860.98, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17210.07, "90th_percentile": 17210.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17210.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3059.31, "90th_percentile": 3059.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3059.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12769.23, "90th_percentile": 21488.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 17298.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5165", "type": "APC" } ], "description": "Level 5 ENT Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18353.02, "90th_percentile": 46351.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 34123.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5219.49, "90th_percentile": 9128.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 5528.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 29099.84, "90th_percentile": 29099.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29099.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 10121.41, "90th_percentile": 10121.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10121.41, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3555.0, "90th_percentile": 6393.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4504.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18529.41, "90th_percentile": 28562.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 20001.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5220.49, "90th_percentile": 5566.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5530.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 12497.44, "90th_percentile": 13454.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12694.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 6054.49, "90th_percentile": 8437.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 6087.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4750.77, "90th_percentile": 4750.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4750.77, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 25784.17, "90th_percentile": 39156.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33206.39, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 5197.03, "90th_percentile": 5197.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5197.03, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 7155.06, "90th_percentile": 7155.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7155.06, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5073.49, "90th_percentile": 5534.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 5531.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19054.69, "90th_percentile": 39587.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32522.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 11356.45, "90th_percentile": 17619.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15705.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 5531.09, "90th_percentile": 7217.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5531.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5402.47, "90th_percentile": 5402.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5402.47, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5665.41, "90th_percentile": 5665.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5665.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 41339.07, "90th_percentile": 41339.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41339.07, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15986.85, "90th_percentile": 22833.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20269.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 5123.03, "90th_percentile": 5123.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5123.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5114.04, "90th_percentile": 7433.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 5587.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18927.85, "90th_percentile": 22842.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 21499.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5166", "type": "APC" } ], "description": "Cochlear Implant Procedure", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28061.0, "90th_percentile": 29886.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29723.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 54098.79, "90th_percentile": 54098.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54098.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 30897.62, "90th_percentile": 30897.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30897.62, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63079.0, "90th_percentile": 66965.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63079.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 32004.21, "90th_percentile": 32004.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32004.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29709.68, "90th_percentile": 29871.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29802.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 30309.67, "90th_percentile": 30309.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30309.67, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 29712.68, "90th_percentile": 29712.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29712.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 60146.81, "90th_percentile": 71120.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64798.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 45568.86, "90th_percentile": 45568.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45568.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 35152.32, "90th_percentile": 35152.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35152.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 11617.79, "90th_percentile": 11617.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11617.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30005.52, "90th_percentile": 30005.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30005.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 45835.31, "90th_percentile": 45835.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45835.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5181", "type": "APC" } ], "description": "Level 1 Vascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 14772.17, "90th_percentile": 14772.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14772.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 559.94, "90th_percentile": 1057.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 579.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 3191.09, "90th_percentile": 3191.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3191.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3414.0, "90th_percentile": 3943.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 3714.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 911.47, "90th_percentile": 911.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 911.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 559.48, "90th_percentile": 659.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 583.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1635.43, "90th_percentile": 2231.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1635.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 5250.9, "90th_percentile": 5250.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5250.9, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 3963.44, "90th_percentile": 3963.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3963.44, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 3113.4, "90th_percentile": 3113.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3113.4, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 703.15, "90th_percentile": 703.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 703.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 559.48, "90th_percentile": 1320.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 659.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3643.7, "90th_percentile": 5662.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 3809.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2948.8, "90th_percentile": 2948.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2948.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 584.15, "90th_percentile": 1121.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 584.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3448.47, "90th_percentile": 3448.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3448.47, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3786.63, "90th_percentile": 4376.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3885.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1763.31, "90th_percentile": 1763.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1763.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 466.5, "90th_percentile": 3551.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 622.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3706.76, "90th_percentile": 9174.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 3879.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5182", "type": "APC" } ], "description": "Level 2 Vascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 2175.74, "90th_percentile": 6245.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5353.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1160.54, "90th_percentile": 1457.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 1450.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 1214.69, "90th_percentile": 1214.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1214.69, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 963.7, "90th_percentile": 963.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 963.7, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3352.93, "90th_percentile": 14500.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 3714.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 699.69, "90th_percentile": 699.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 699.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1426.32, "90th_percentile": 2838.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1454.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1067.54, "90th_percentile": 6390.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2750.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 819.46, "90th_percentile": 2199.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 819.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4494.64, "90th_percentile": 5728.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4494.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 2279.39, "90th_percentile": 5844.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5287.79, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1355.27, "90th_percentile": 1355.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1355.27, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 963.7, "90th_percentile": 5851.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 963.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1058.82, "90th_percentile": 1459.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1450.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4286.64, "90th_percentile": 14774.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 5434.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2938.4, "90th_percentile": 2938.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2938.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1426.32, "90th_percentile": 1426.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1426.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 1454.16, "90th_percentile": 1454.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1454.16, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 731.21, "90th_percentile": 2009.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1137.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9285.3, "90th_percentile": 19506.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9285.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 3008.99, "90th_percentile": 3008.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3008.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1440.59, "90th_percentile": 1474.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1465.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2704.79, "90th_percentile": 9999.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4731.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5183", "type": "APC" } ], "description": "Level 3 Vascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9249.16, "90th_percentile": 44435.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 12967.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2596.26, "90th_percentile": 2946.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "82", "median_amount": 2939.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 20999.95, "90th_percentile": 31257.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23625.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2854.32, "90th_percentile": 2854.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2854.32, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1956.33, "90th_percentile": 3949.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2205.13, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12493.38, "90th_percentile": 34526.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "90", "median_amount": 15689.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1946.73, "90th_percentile": 3779.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3024.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2709.16, "90th_percentile": 2949.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 2939.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 3041.26, "90th_percentile": 10569.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 4812.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3051.5, "90th_percentile": 7358.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3222.6, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9172.12, "90th_percentile": 9172.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9172.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2279.95, "90th_percentile": 5769.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 2624.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13300.86, "90th_percentile": 15135.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13920.69, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 10316.98, "90th_percentile": 78807.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 19622.31, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 2449.25, "90th_percentile": 2449.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2449.25, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3039.18, "90th_percentile": 3949.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3160.48, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2471.27, "90th_percentile": 2949.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 2939.26, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9513.43, "90th_percentile": 69299.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 11781.54, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 5446.76, "90th_percentile": 13084.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11069.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2606.06, "90th_percentile": 2946.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 2939.27, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13846.29, "90th_percentile": 13846.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13846.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2034.42, "90th_percentile": 6222.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3160.48, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2365.87, "90th_percentile": 5606.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2445.47, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9222.6, "90th_percentile": 29899.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 10843.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1929.19, "90th_percentile": 4942.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1994.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2374.92, "90th_percentile": 2976.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 2871.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8245.3, "90th_percentile": 30408.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 10297.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5184", "type": "APC" } ], "description": "Level 4 Vascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9883.97, "90th_percentile": 30124.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 19199.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4038.45, "90th_percentile": 5058.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "71", "median_amount": 5048.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 13695.49, "90th_percentile": 20422.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19267.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 4199.99, "90th_percentile": 4955.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4199.99, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3949.31, "90th_percentile": 7479.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5754.59, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20001.0, "90th_percentile": 35485.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "106", "median_amount": 31312.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 3801.87, "90th_percentile": 5547.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 5329.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4655.02, "90th_percentile": 5178.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 5048.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31196.84, "90th_percentile": 31196.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31196.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 5447.11, "90th_percentile": 11286.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 7617.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3832.59, "90th_percentile": 5766.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 5566.14, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9942.68, "90th_percentile": 18821.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9942.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 4428.29, "90th_percentile": 8466.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "55", "median_amount": 6459.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4078.84, "90th_percentile": 4078.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4078.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 28935.32, "90th_percentile": 32513.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28935.32, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 9685.13, "90th_percentile": 35286.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 21310.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 27431.52, "90th_percentile": 27431.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27431.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 4716.09, "90th_percentile": 6757.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4716.09, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 215.0, "90th_percentile": 215.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 215.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 5762.13, "90th_percentile": 7081.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5774.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4148.45, "90th_percentile": 5057.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "60", "median_amount": 4881.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9913.47, "90th_percentile": 23677.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 19864.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 6776.42, "90th_percentile": 14633.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11169.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 4709.98, "90th_percentile": 7254.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5054.87, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21151.24, "90th_percentile": 21151.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21151.24, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 5204.47, "90th_percentile": 5204.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5204.47, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3160.48, "90th_percentile": 8171.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 5758.2, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4199.99, "90th_percentile": 5699.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4199.99, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15715.94, "90th_percentile": 15715.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15715.94, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11108.41, "90th_percentile": 26268.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 19272.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 5456.34, "90th_percentile": 5472.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 5466.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4078.84, "90th_percentile": 5203.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "58", "median_amount": 4967.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14662.1, "90th_percentile": 26409.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 20467.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5191", "type": "APC" } ], "description": "Level 1 Endovascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 7976.6, "90th_percentile": 22660.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 9782.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2636.12, "90th_percentile": 3011.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "217", "median_amount": 3006.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 10242.47, "90th_percentile": 24666.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10401.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2829.77, "90th_percentile": 3130.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2829.77, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2439.45, "90th_percentile": 3971.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2439.45, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12907.47, "90th_percentile": 16654.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "157", "median_amount": 15664.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2334.3, "90th_percentile": 4307.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2334.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2402.9, "90th_percentile": 3011.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "123", "median_amount": 3003.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14664.82, "90th_percentile": 14664.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14664.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2824.13, "90th_percentile": 7266.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5291.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 2102.97, "90th_percentile": 4432.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 2355.33, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5039.21, "90th_percentile": 5326.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5307.58, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2733.86, "90th_percentile": 2944.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 2733.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12173.08, "90th_percentile": 26186.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14927.17, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 8285.27, "90th_percentile": 13172.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 10926.24, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 22146.56, "90th_percentile": 22146.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22146.56, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 2514.92, "90th_percentile": 3064.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 2908.32, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 2439.45, "90th_percentile": 2439.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2439.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2513.62, "90th_percentile": 3015.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "161", "median_amount": 3003.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8829.87, "90th_percentile": 19655.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 10795.43, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 3907.48, "90th_percentile": 10473.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7966.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2902.06, "90th_percentile": 3003.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 3003.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2345.81, "90th_percentile": 3681.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 2439.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2499.02, "90th_percentile": 4429.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2499.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13251.73, "90th_percentile": 15854.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13251.73, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9018.03, "90th_percentile": 18898.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 11165.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2224.48, "90th_percentile": 3488.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 2313.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2426.93, "90th_percentile": 3046.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "129", "median_amount": 2983.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8693.97, "90th_percentile": 17561.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 10864.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5192", "type": "APC" } ], "description": "Level 2 Endovascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5325.48, "90th_percentile": 10132.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7044.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 37811.96, "90th_percentile": 37811.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37811.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26435.15, "90th_percentile": 39047.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36119.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5155.52, "90th_percentile": 10125.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5330.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 6557.59, "90th_percentile": 6557.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6557.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 15209.5, "90th_percentile": 15209.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15209.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 5851.39, "90th_percentile": 5851.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5851.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4887.1, "90th_percentile": 10133.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 5333.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 10091.68, "90th_percentile": 10091.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10091.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5626.8, "90th_percentile": 5626.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5626.8, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13386.26, "90th_percentile": 13386.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13386.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5377.57, "90th_percentile": 10507.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5389.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 16970.05, "90th_percentile": 30332.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20903.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5193", "type": "APC" } ], "description": "Level 3 Endovascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20149.02, "90th_percentile": 48744.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 27288.24, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9803.9, "90th_percentile": 10780.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "126", "median_amount": 10594.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 37007.3, "90th_percentile": 51731.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37007.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 10719.92, "90th_percentile": 10811.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10719.92, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10317.0, "90th_percentile": 10564.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10317.0, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27530.66, "90th_percentile": 53216.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "93", "median_amount": 46060.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 97.04, "90th_percentile": 97.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 97.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8472.24, "90th_percentile": 15363.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "79", "median_amount": 10590.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 33306.8, "90th_percentile": 33306.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33306.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 11328.43, "90th_percentile": 31511.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14220.09, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 2022.25, "90th_percentile": 8020.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6411.22, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26878.26, "90th_percentile": 26878.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26878.26, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1642.63, "90th_percentile": 11839.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 8239.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 35057.55, "90th_percentile": 36300.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35057.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 12564.08, "90th_percentile": 37069.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24341.09, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 10306.43, "90th_percentile": 17110.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10582.76, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 10564.71, "90th_percentile": 13103.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11807.17, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9001.76, "90th_percentile": 12702.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "78", "median_amount": 10592.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13005.5, "90th_percentile": 46801.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 25675.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 18217.29, "90th_percentile": 18217.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18217.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 10257.11, "90th_percentile": 15616.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 10590.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 68420.67, "90th_percentile": 68420.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68420.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9415.93, "90th_percentile": 13604.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 10564.71, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8811.54, "90th_percentile": 8811.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8811.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21618.55, "90th_percentile": 54361.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 28030.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 9823.83, "90th_percentile": 11196.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10018.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8556.96, "90th_percentile": 12836.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "59", "median_amount": 10462.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20291.49, "90th_percentile": 48557.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 34483.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5194", "type": "APC" } ], "description": "Level 4 Endovascular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3726.67, "90th_percentile": 37540.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30785.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 454.24, "90th_percentile": 16782.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 16768.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 36725.65, "90th_percentile": 36725.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36725.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10221.86, "90th_percentile": 10221.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10221.86, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 46498.0, "90th_percentile": 65997.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 58454.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 9406.62, "90th_percentile": 9406.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9406.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15616.72, "90th_percentile": 16774.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 16479.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 15872.7, "90th_percentile": 15872.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15872.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 15429.42, "90th_percentile": 15429.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15429.42, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 7923.41, "90th_percentile": 20318.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19288.37, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 50395.63, "90th_percentile": 50395.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50395.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 25618.79, "90th_percentile": 53939.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37145.33, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 21514.51, "90th_percentile": 21514.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21514.51, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 17898.13, "90th_percentile": 17898.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17898.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16278.74, "90th_percentile": 16778.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 16380.59, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 28852.98, "90th_percentile": 41539.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31385.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 13535.29, "90th_percentile": 14224.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13535.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 16430.64, "90th_percentile": 16774.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16768.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10564.71, "90th_percentile": 17898.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17211.16, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 36104.24, "90th_percentile": 53236.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37436.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 16972.36, "90th_percentile": 16972.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16972.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13549.15, "90th_percentile": 16944.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 16642.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 32048.81, "90th_percentile": 44754.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 37046.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5200", "type": "APC" } ], "description": "Implantation Wireless PA Pressure Monitor", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26243.77, "90th_percentile": 26243.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26243.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21995.28, "90th_percentile": 21995.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21995.28, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 57704.49, "90th_percentile": 57704.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57704.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31.53, "90th_percentile": 26813.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26445.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5211", "type": "APC" } ], "description": "Level 1 Electrophysiologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 22918.0, "90th_percentile": 22918.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22918.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5212", "type": "APC" } ], "description": "Level 2 Electrophysiologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7093.09, "90th_percentile": 7093.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7093.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 26002.44, "90th_percentile": 39577.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32189.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7091.79, "90th_percentile": 7091.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7091.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 30659.33, "90th_percentile": 48454.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30659.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14599.23, "90th_percentile": 14599.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14599.23, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31918.18, "90th_percentile": 31918.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31918.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 38271.55, "90th_percentile": 47148.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40968.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5213", "type": "APC" } ], "description": "Level 3 Electrophysiologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 44339.96, "90th_percentile": 68480.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 50608.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21154.34, "90th_percentile": 22927.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "157", "median_amount": 22916.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 50627.45, "90th_percentile": 82457.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65701.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 21709.03, "90th_percentile": 23831.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23531.66, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15181.94, "90th_percentile": 15181.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15181.94, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60549.53, "90th_percentile": 66965.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "151", "median_amount": 63079.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 14527.55, "90th_percentile": 14527.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14527.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21157.75, "90th_percentile": 22917.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "89", "median_amount": 22915.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 851.44, "90th_percentile": 25205.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 22251.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31887.06, "90th_percentile": 31887.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31887.06, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 17014.24, "90th_percentile": 17014.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 17014.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 61824.63, "90th_percentile": 63312.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 63102.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 48376.11, "90th_percentile": 59860.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 50993.77, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 78571.02, "90th_percentile": 78571.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78571.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 23226.83, "90th_percentile": 23376.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23281.83, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 15181.94, "90th_percentile": 15181.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15181.94, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21152.05, "90th_percentile": 22911.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "89", "median_amount": 22911.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 55013.42, "90th_percentile": 99975.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 77639.46, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 32016.64, "90th_percentile": 43020.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 39988.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 22821.8, "90th_percentile": 22910.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 22909.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14599.23, "90th_percentile": 15181.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 15181.94, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22000.13, "90th_percentile": 23825.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22000.13, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 88588.38, "90th_percentile": 102277.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 92684.21, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 51820.5, "90th_percentile": 83528.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 69655.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 14396.67, "90th_percentile": 17421.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14396.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18510.71, "90th_percentile": 23146.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "64", "median_amount": 23138.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 51171.98, "90th_percentile": 81039.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 71467.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5221", "type": "APC" } ], "description": "Level 1 Pacemaker and Similar Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15172.63, "90th_percentile": 15172.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15172.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74845.75, "90th_percentile": 74845.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 74845.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 285.0, "90th_percentile": 285.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 285.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 45696.96, "90th_percentile": 45696.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45696.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2605.99, "90th_percentile": 2605.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2605.99, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 581.69, "90th_percentile": 581.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 581.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 59893.37, "90th_percentile": 59893.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59893.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5222", "type": "APC" } ], "description": "Level 2 Pacemaker and Similar Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 20951.48, "90th_percentile": 71763.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 54695.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7385.46, "90th_percentile": 22927.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 21158.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 21495.51, "90th_percentile": 21495.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21495.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 29.44, "90th_percentile": 19129.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7894.77, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33253.2, "90th_percentile": 82187.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 82187.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 7554.48, "90th_percentile": 8520.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7554.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7728.46, "90th_percentile": 22909.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 22909.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 24963.74, "90th_percentile": 24963.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24963.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 27569.43, "90th_percentile": 27569.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27569.43, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 8847.59, "90th_percentile": 8847.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8847.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 68800.83, "90th_percentile": 72347.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68800.83, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 7886.18, "90th_percentile": 23376.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23376.83, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 10119.63, "90th_percentile": 19129.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19129.33, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7728.46, "90th_percentile": 22918.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "47", "median_amount": 22458.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21710.12, "90th_percentile": 97494.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 93437.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 21129.85, "90th_percentile": 60711.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52255.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 7735.24, "90th_percentile": 22916.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 22705.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7894.77, "90th_percentile": 19129.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7894.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6430.07, "90th_percentile": 6430.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6430.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 126605.35, "90th_percentile": 126605.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 126605.35, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20733.88, "90th_percentile": 103167.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 95793.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 18139.88, "90th_percentile": 18139.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18139.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7805.74, "90th_percentile": 23145.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 21369.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21480.25, "90th_percentile": 103592.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 92901.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5223", "type": "APC" } ], "description": "Level 3 Pacemaker and Similar Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 21936.67, "90th_percentile": 21936.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21936.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9405.46, "90th_percentile": 9799.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 9780.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33007.68, "90th_percentile": 57793.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36623.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9469.16, "90th_percentile": 9780.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 9779.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2407.75, "90th_percentile": 2407.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2407.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 17093.94, "90th_percentile": 17093.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17093.94, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 67020.37, "90th_percentile": 67020.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67020.37, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 9972.41, "90th_percentile": 9972.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9972.41, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9322.16, "90th_percentile": 17353.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 9781.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21011.04, "90th_percentile": 55793.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27866.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 9739.76, "90th_percentile": 11227.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 9779.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7894.77, "90th_percentile": 7894.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7894.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8131.11, "90th_percentile": 8131.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8131.11, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 25275.56, "90th_percentile": 25275.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25275.56, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 7486.42, "90th_percentile": 7486.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7486.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7896.55, "90th_percentile": 9890.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 9605.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 23774.9, "90th_percentile": 43348.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23774.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5224", "type": "APC" } ], "description": "Level 4 Pacemaker and Similar Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17132.59, "90th_percentile": 17132.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17132.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16893.62, "90th_percentile": 23364.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 17813.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 41866.81, "90th_percentile": 41866.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41866.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 58222.67, "90th_percentile": 63079.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58222.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17422.35, "90th_percentile": 17817.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17506.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 14023.99, "90th_percentile": 14023.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14023.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 8847.59, "90th_percentile": 8847.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8847.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 14667.62, "90th_percentile": 14667.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14667.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17360.98, "90th_percentile": 17819.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 17818.25, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 29406.35, "90th_percentile": 29406.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29406.35, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 47252.15, "90th_percentile": 47252.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47252.15, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 7486.42, "90th_percentile": 7486.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7486.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 96.41, "90th_percentile": 17989.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4299.02, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 68529.29, "90th_percentile": 68529.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 68529.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5231", "type": "APC" } ], "description": "Level 1 ICD and Similar Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 13928.15, "90th_percentile": 13928.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13928.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20961.19, "90th_percentile": 22973.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20968.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 54383.99, "90th_percentile": 54383.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 54383.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 56488.0, "90th_percentile": 63006.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62913.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20998.54, "90th_percentile": 20998.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20998.54, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 26400.33, "90th_percentile": 26400.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26400.33, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 32023.99, "90th_percentile": 32023.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32023.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 40065.31, "90th_percentile": 40065.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40065.31, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20510.39, "90th_percentile": 20970.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20510.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 29144.41, "90th_percentile": 29144.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29144.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 20968.0, "90th_percentile": 20968.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20968.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20742.76, "90th_percentile": 20742.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20742.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20764.11, "90th_percentile": 21179.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21176.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 33460.88, "90th_percentile": 33460.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33460.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5232", "type": "APC" } ], "description": "Level 2 ICD and Similar Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 63106.16, "90th_percentile": 71292.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 70648.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28297.97, "90th_percentile": 29964.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 29940.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 30868.57, "90th_percentile": 30868.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30868.57, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27343.2, "90th_percentile": 27776.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27343.2, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63078.99, "90th_percentile": 79456.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 66965.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 28.17, "90th_percentile": 28.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25791.94, "90th_percentile": 29948.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 29696.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 15806.76, "90th_percentile": 19900.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18534.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 26400.33, "90th_percentile": 29823.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26400.33, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 27568.2, "90th_percentile": 31223.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30643.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24191.88, "90th_percentile": 24191.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24191.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 119000.03, "90th_percentile": 119000.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 119000.03, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 30960.2, "90th_percentile": 30960.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30960.2, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 29897.8, "90th_percentile": 29897.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29897.8, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25773.49, "90th_percentile": 29950.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 29940.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 39620.42, "90th_percentile": 74560.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39620.42, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 14667.76, "90th_percentile": 14667.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14667.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 29607.25, "90th_percentile": 29607.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29607.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27343.2, "90th_percentile": 27343.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27343.2, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24910.45, "90th_percentile": 28790.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24910.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 51079.66, "90th_percentile": 51079.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51079.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 24933.69, "90th_percentile": 25949.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24993.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27280.6, "90th_percentile": 30248.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 29916.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 45278.49, "90th_percentile": 262677.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 65367.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5241", "type": "APC" } ], "description": "Level 1 Blood Product Exchange and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 27945.56, "90th_percentile": 27945.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27945.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2369.12, "90th_percentile": 2484.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2476.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 7743.0, "90th_percentile": 8013.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7743.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1036.93, "90th_percentile": 1036.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1036.93, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3943.0, "90th_percentile": 19942.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6209.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2648.94, "90th_percentile": 2648.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2648.94, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2476.41, "90th_percentile": 2479.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2476.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 2476.62, "90th_percentile": 2476.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2476.62, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1123.01, "90th_percentile": 2563.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1130.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 10479.94, "90th_percentile": 12590.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10479.94, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 487.37, "90th_percentile": 487.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 487.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1795.14, "90th_percentile": 2475.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2204.84, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 2349.55, "90th_percentile": 2349.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2349.55, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1696.76, "90th_percentile": 2278.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1872.49, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 2596.19, "90th_percentile": 2596.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2596.19, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12688.79, "90th_percentile": 14388.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12688.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2462.48, "90th_percentile": 2501.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2462.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4996.67, "90th_percentile": 19552.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7805.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5242", "type": "APC" } ], "description": "Level 2 Blood Product Exchange and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1496.53, "90th_percentile": 1496.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1496.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14486.6, "90th_percentile": 14486.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14486.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5301", "type": "APC" } ], "description": "Level 1 Upper GI Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3556.07, "90th_percentile": 11665.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "92", "median_amount": 5891.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 678.54, "90th_percentile": 2581.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "186", "median_amount": 879.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 3031.13, "90th_percentile": 13754.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5357.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 741.33, "90th_percentile": 917.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 910.56, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 939.72, "90th_percentile": 4017.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 977.23, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2361.52, "90th_percentile": 3943.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "248", "median_amount": 3714.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 804.07, "90th_percentile": 2657.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 935.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 571.73, "90th_percentile": 2280.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "93", "median_amount": 842.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1095.17, "90th_percentile": 6079.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 2515.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 842.44, "90th_percentile": 3715.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 1618.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2995.45, "90th_percentile": 7104.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6752.34, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1053.13, "90th_percentile": 2994.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "139", "median_amount": 1095.17, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 707.42, "90th_percentile": 3451.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2303.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7393.51, "90th_percentile": 30334.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15649.07, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 4455.44, "90th_percentile": 19705.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 5835.93, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 8270.0, "90th_percentile": 8270.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8270.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 823.79, "90th_percentile": 1732.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 893.4, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 840.3, "90th_percentile": 1824.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 977.23, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 424.73, "90th_percentile": 2052.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "122", "median_amount": 878.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3871.89, "90th_percentile": 12662.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "100", "median_amount": 5644.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 1727.36, "90th_percentile": 8580.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6122.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 542.34, "90th_percentile": 1715.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 882.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15853.46, "90th_percentile": 15853.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15853.46, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 20.0, "90th_percentile": 20.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20.0, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 939.72, "90th_percentile": 3153.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "60", "median_amount": 977.23, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 741.33, "90th_percentile": 2969.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 741.33, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6681.28, "90th_percentile": 9488.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6681.28, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3526.57, "90th_percentile": 18936.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "69", "median_amount": 5542.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 891.11, "90th_percentile": 2862.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 926.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 590.29, "90th_percentile": 2263.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "105", "median_amount": 842.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4086.49, "90th_percentile": 13006.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "139", "median_amount": 5782.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5302", "type": "APC" } ], "description": "Level 2 Upper GI Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5950.51, "90th_percentile": 13542.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "60", "median_amount": 8126.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 1417.19, "90th_percentile": 1417.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1417.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1417.19, "90th_percentile": 1778.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "176", "median_amount": 1772.93, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 6274.01, "90th_percentile": 16907.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8334.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 1473.88, "90th_percentile": 1473.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1473.88, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 977.23, "90th_percentile": 3328.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1700.79, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8235.5, "90th_percentile": 11886.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "192", "median_amount": 9601.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 935.11, "90th_percentile": 2728.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 1402.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1417.19, "90th_percentile": 2191.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "97", "median_amount": 1771.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8638.25, "90th_percentile": 8638.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8638.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1878.25, "90th_percentile": 8265.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 3560.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1820.58, "90th_percentile": 4321.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 2188.57, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2061.62, "90th_percentile": 2957.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2061.62, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1095.17, "90th_percentile": 4333.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 1642.76, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1431.37, "90th_percentile": 1431.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1431.37, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14144.2, "90th_percentile": 19999.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14578.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 6363.35, "90th_percentile": 15131.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 9369.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 13689.96, "90th_percentile": 13689.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13689.96, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1357.64, "90th_percentile": 1901.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1807.64, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 977.23, "90th_percentile": 3648.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 977.23, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1327.15, "90th_percentile": 1780.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "121", "median_amount": 1771.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6003.13, "90th_percentile": 14285.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "77", "median_amount": 8833.21, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 3631.8, "90th_percentile": 7879.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6073.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1438.29, "90th_percentile": 3319.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 1778.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 1940.37, "90th_percentile": 1940.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1940.37, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 977.23, "90th_percentile": 3614.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 1409.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2302.72, "90th_percentile": 2302.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2302.72, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8216.25, "90th_percentile": 8216.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8216.25, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6111.14, "90th_percentile": 13120.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 9139.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 926.68, "90th_percentile": 3582.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1953.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1382.51, "90th_percentile": 1797.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "106", "median_amount": 1786.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6074.97, "90th_percentile": 14978.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "110", "median_amount": 8957.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5303", "type": "APC" } ], "description": "Level 3 Upper GI Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17842.78, "90th_percentile": 17842.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17842.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2842.26, "90th_percentile": 3561.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 3552.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 30983.75, "90th_percentile": 30983.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30983.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2955.95, "90th_percentile": 2955.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2955.95, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2468.93, "90th_percentile": 2468.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2468.93, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19261.95, "90th_percentile": 27425.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 23533.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2842.26, "90th_percentile": 3552.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 3416.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 7814.53, "90th_percentile": 12535.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8774.93, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 10461.43, "90th_percentile": 10461.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10461.43, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2766.91, "90th_percentile": 2846.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2766.91, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 3625.34, "90th_percentile": 3625.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3625.34, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9934.7, "90th_percentile": 9934.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9934.7, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3102.03, "90th_percentile": 8174.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3521.89, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18339.59, "90th_percentile": 26391.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25282.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 9588.3, "90th_percentile": 10947.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10843.01, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 3287.64, "90th_percentile": 3559.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3559.63, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2468.93, "90th_percentile": 4547.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3404.75, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3710.02, "90th_percentile": 3710.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3710.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12363.74, "90th_percentile": 19879.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18545.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2462.89, "90th_percentile": 2556.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2462.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2870.68, "90th_percentile": 3596.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 3181.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18155.09, "90th_percentile": 20287.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 18908.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5311", "type": "APC" } ], "description": "Level 1 Lower GI Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 4561.13, "90th_percentile": 12285.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 5367.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 851.39, "90th_percentile": 2831.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 851.39, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 4337.36, "90th_percentile": 24163.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12669.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 1648.34, "90th_percentile": 1648.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1648.34, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1114.91, "90th_percentile": 2536.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1983.25, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3414.0, "90th_percentile": 8761.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 3943.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1066.85, "90th_percentile": 2874.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1066.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 845.78, "90th_percentile": 2757.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 851.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1408.17, "90th_percentile": 2670.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 2287.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 924.24, "90th_percentile": 1474.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1076.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8761.28, "90th_percentile": 8761.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8761.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1249.47, "90th_percentile": 3533.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 1249.47, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10981.29, "90th_percentile": 10981.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10981.29, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 5026.77, "90th_percentile": 12973.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5544.73, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 5359.56, "90th_percentile": 5359.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5359.56, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 868.77, "90th_percentile": 1789.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 868.77, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1114.91, "90th_percentile": 3572.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1114.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 851.39, "90th_percentile": 1302.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 851.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3281.03, "90th_percentile": 11864.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 5312.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2775.12, "90th_percentile": 7507.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4189.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 851.39, "90th_percentile": 2901.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 851.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 1145.08, "90th_percentile": 1145.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1145.08, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1114.91, "90th_percentile": 3825.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1114.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 885.45, "90th_percentile": 885.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 885.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4046.85, "90th_percentile": 15102.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5315.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1057.24, "90th_percentile": 3939.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2699.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 822.12, "90th_percentile": 2996.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 879.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4118.65, "90th_percentile": 9912.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 5309.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5312", "type": "APC" } ], "description": "Level 2 Lower GI Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5951.95, "90th_percentile": 13401.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 7523.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1050.96, "90th_percentile": 2527.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "90", "median_amount": 1101.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 7398.48, "90th_percentile": 7634.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7466.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2369.63, "90th_percentile": 2369.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2369.63, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1114.91, "90th_percentile": 1361.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1114.91, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8940.3, "90th_percentile": 14659.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "107", "median_amount": 9773.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1066.85, "90th_percentile": 1811.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1066.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1050.96, "90th_percentile": 2276.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "47", "median_amount": 1102.22, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9206.0, "90th_percentile": 9206.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9206.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2230.43, "90th_percentile": 5738.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 3067.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1573.58, "90th_percentile": 3235.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1638.31, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1249.47, "90th_percentile": 3123.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1249.47, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1112.09, "90th_percentile": 1112.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1112.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14133.48, "90th_percentile": 14133.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14133.48, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 6561.4, "90th_percentile": 13686.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 7417.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 10097.08, "90th_percentile": 10097.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10097.08, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1123.55, "90th_percentile": 2132.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1570.25, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1114.91, "90th_percentile": 1114.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1114.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1101.08, "90th_percentile": 1973.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "66", "median_amount": 1101.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6370.52, "90th_percentile": 15863.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 8451.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 3478.87, "90th_percentile": 9262.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5565.45, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1050.96, "90th_percentile": 2090.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1101.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11542.44, "90th_percentile": 11542.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11542.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 2824.54, "90th_percentile": 2824.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2824.54, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1114.91, "90th_percentile": 2350.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1114.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4924.22, "90th_percentile": 4924.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4924.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20912.95, "90th_percentile": 20912.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20912.95, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5994.89, "90th_percentile": 20051.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 8339.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1083.74, "90th_percentile": 4154.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1524.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1112.09, "90th_percentile": 2878.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 1668.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6203.32, "90th_percentile": 19338.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "59", "median_amount": 9000.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5313", "type": "APC" } ], "description": "Level 3 Lower GI Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 9101.48, "90th_percentile": 18803.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 12817.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2560.96, "90th_percentile": 2570.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 2560.96, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 14194.44, "90th_percentile": 14194.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14194.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1361.91, "90th_percentile": 1361.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1361.91, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6745.15, "90th_percentile": 13809.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 9206.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2201.06, "90th_percentile": 2201.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2201.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2500.61, "90th_percentile": 2567.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2560.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 3494.37, "90th_percentile": 9542.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6663.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3523.69, "90th_percentile": 4280.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3523.69, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8775.8, "90th_percentile": 8775.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8775.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1526.28, "90th_percentile": 2577.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2577.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18108.7, "90th_percentile": 18108.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18108.7, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 13499.58, "90th_percentile": 42624.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15073.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 26195.63, "90th_percentile": 26195.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26195.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7569.02, "90th_percentile": 7569.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7569.02, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1361.91, "90th_percentile": 1361.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1361.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2560.96, "90th_percentile": 2563.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2560.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10440.15, "90th_percentile": 24674.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12781.87, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 3112.13, "90th_percentile": 3112.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3112.13, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2560.95, "90th_percentile": 2560.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2560.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2211.92, "90th_percentile": 3284.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2300.21, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8752.67, "90th_percentile": 18084.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 13595.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2181.23, "90th_percentile": 2181.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2181.23, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2530.72, "90th_percentile": 2594.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 2586.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8615.2, "90th_percentile": 20163.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 12231.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5331", "type": "APC" } ], "description": "Complex GI Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 5566.35, "90th_percentile": 22498.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12506.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4608.05, "90th_percentile": 5566.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5558.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18230.85, "90th_percentile": 34917.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 27845.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 5146.7, "90th_percentile": 5146.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5146.7, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4447.18, "90th_percentile": 5558.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 5558.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 7548.77, "90th_percentile": 11364.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9765.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3462.04, "90th_percentile": 3462.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3462.04, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9345.48, "90th_percentile": 9345.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9345.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 4018.44, "90th_percentile": 6125.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4018.44, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 21715.42, "90th_percentile": 21715.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21715.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5287.23, "90th_percentile": 6047.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5562.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 25483.38, "90th_percentile": 39593.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29760.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 7485.67, "90th_percentile": 11886.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7485.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 5565.78, "90th_percentile": 5565.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5565.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3812.81, "90th_percentile": 5851.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3812.81, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 26634.87, "90th_percentile": 26634.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26634.87, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18022.25, "90th_percentile": 21239.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19214.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 3400.22, "90th_percentile": 3400.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3400.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4491.65, "90th_percentile": 8224.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5614.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14856.12, "90th_percentile": 23747.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17375.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5341", "type": "APC" } ], "description": "Level 1 Abdominal/Peritoneal/Biliary and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18136.77, "90th_percentile": 64970.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23778.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2928.08, "90th_percentile": 7011.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 3299.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 12604.9, "90th_percentile": 27070.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24735.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1707.81, "90th_percentile": 1707.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1707.81, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14036.8, "90th_percentile": 21168.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 15689.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2807.9, "90th_percentile": 4336.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2807.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2908.48, "90th_percentile": 3301.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2991.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2636.46, "90th_percentile": 27858.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5946.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3161.44, "90th_percentile": 4419.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3449.31, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1674.22, "90th_percentile": 4777.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3419.79, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6219.41, "90th_percentile": 6219.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6219.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 29924.55, "90th_percentile": 29924.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29924.55, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 2934.38, "90th_percentile": 2934.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2934.38, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2844.78, "90th_percentile": 8289.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3295.58, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9768.17, "90th_percentile": 28713.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12439.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 10318.38, "90th_percentile": 10318.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10318.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 3088.66, "90th_percentile": 3401.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3295.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1260.17, "90th_percentile": 4085.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3051.51, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2652.85, "90th_percentile": 2652.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2652.85, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11798.11, "90th_percentile": 24589.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18356.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 4955.38, "90th_percentile": 4955.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4955.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3118.49, "90th_percentile": 5156.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 3336.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9601.54, "90th_percentile": 22015.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 19529.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5342", "type": "APC" } ], "description": "Level 2 Abdominal/Peritoneal/Biliary and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 2530.37, "90th_percentile": 55413.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28969.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5826.94, "90th_percentile": 8500.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6216.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 29318.77, "90th_percentile": 29318.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29318.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14996.0, "90th_percentile": 38467.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 15689.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 4065.32, "90th_percentile": 4065.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4065.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5832.84, "90th_percentile": 8981.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5833.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 12590.89, "90th_percentile": 25106.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15920.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 4761.19, "90th_percentile": 4761.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4761.19, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 59444.78, "90th_percentile": 59444.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 59444.78, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 4256.43, "90th_percentile": 4256.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4256.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5836.94, "90th_percentile": 7987.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7243.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 29230.64, "90th_percentile": 65323.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33439.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 32093.17, "90th_percentile": 32093.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32093.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 7417.94, "90th_percentile": 7417.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7417.94, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 22190.52, "90th_percentile": 22190.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22190.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19048.12, "90th_percentile": 22778.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22185.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5361", "type": "APC" } ], "description": "Level 1 Laparoscopy and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 17380.91, "90th_percentile": 44781.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "172", "median_amount": 29166.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4358.7, "90th_percentile": 8452.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "104", "median_amount": 5452.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 20140.11, "90th_percentile": 49377.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 30447.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2542.33, "90th_percentile": 6616.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 4924.54, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23719.64, "90th_percentile": 40051.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "487", "median_amount": 26701.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 3338.36, "90th_percentile": 5413.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 4971.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4358.7, "90th_percentile": 8015.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "71", "median_amount": 5454.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 25973.56, "90th_percentile": 25973.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25973.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 5785.43, "90th_percentile": 25322.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 10716.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3368.43, "90th_percentile": 14455.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 5833.1, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11828.14, "90th_percentile": 26718.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12049.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 3357.79, "90th_percentile": 7414.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "154", "median_amount": 5722.39, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4402.78, "90th_percentile": 7275.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4402.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27493.25, "90th_percentile": 75647.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 43358.52, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 17545.96, "90th_percentile": 52728.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "89", "median_amount": 28238.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 21484.0, "90th_percentile": 65307.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22597.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 5559.56, "90th_percentile": 13265.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7705.72, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3672.77, "90th_percentile": 3672.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3672.77, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3488.73, "90th_percentile": 6668.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 5233.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4958.37, "90th_percentile": 7122.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "58", "median_amount": 5449.35, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17890.17, "90th_percentile": 48751.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "138", "median_amount": 28935.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 9780.67, "90th_percentile": 17003.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 15151.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 5145.17, "90th_percentile": 7387.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 5455.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 52465.22, "90th_percentile": 52465.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52465.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3423.32, "90th_percentile": 6202.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "62", "median_amount": 5233.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4533.04, "90th_percentile": 6477.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5250.0, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19695.06, "90th_percentile": 59679.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 30830.94, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 16009.09, "90th_percentile": 21732.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "105", "median_amount": 20406.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 3181.31, "90th_percentile": 5788.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 4771.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4402.29, "90th_percentile": 9821.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "74", "median_amount": 5506.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 16689.86, "90th_percentile": 22245.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "265", "median_amount": 20385.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5362", "type": "APC" } ], "description": "Level 2 Laparoscopy and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 18105.26, "90th_percentile": 72892.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "66", "median_amount": 48881.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8079.95, "90th_percentile": 11734.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "90", "median_amount": 9730.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 45887.66, "90th_percentile": 58010.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 48346.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 11926.06, "90th_percentile": 11926.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11926.06, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6888.49, "90th_percentile": 8646.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7909.36, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33725.66, "90th_percentile": 58241.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "220", "median_amount": 40570.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 6591.57, "90th_percentile": 8948.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6799.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7777.95, "90th_percentile": 13028.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 9732.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 12289.03, "90th_percentile": 37021.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 22417.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 2591.03, "90th_percentile": 18330.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 13104.08, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 6081.31, "90th_percentile": 9841.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "65", "median_amount": 8029.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 45687.64, "90th_percentile": 89584.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 68502.59, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 35917.31, "90th_percentile": 85018.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 54906.19, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 119990.27, "90th_percentile": 119990.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 119990.27, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 9370.85, "90th_percentile": 17805.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11418.01, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1396.0, "90th_percentile": 1396.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1396.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 4348.29, "90th_percentile": 8632.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6888.49, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9271.63, "90th_percentile": 12499.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 9731.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 38893.95, "90th_percentile": 76106.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "92", "median_amount": 53364.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 20682.81, "90th_percentile": 34503.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 24658.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 340.37, "90th_percentile": 10102.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 9729.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 9731.93, "90th_percentile": 9731.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9731.93, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6888.49, "90th_percentile": 8632.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 7105.94, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8796.23, "90th_percentile": 8796.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8796.23, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8332.46, "90th_percentile": 112061.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64069.98, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17069.0, "90th_percentile": 23203.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "60", "median_amount": 20546.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 6356.62, "90th_percentile": 8705.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 7103.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7859.7, "90th_percentile": 11742.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "52", "median_amount": 9800.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18587.4, "90th_percentile": 22548.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "156", "median_amount": 20706.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5371", "type": "APC" } ], "description": "Level 1 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 4014.42, "90th_percentile": 4014.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4014.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 224.6, "90th_percentile": 628.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 227.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3714.0, "90th_percentile": 3943.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3714.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 267.19, "90th_percentile": 267.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 267.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1526.28, "90th_percentile": 1526.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1526.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 227.11, "90th_percentile": 377.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 227.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1073.7, "90th_percentile": 1073.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1073.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 227.11, "90th_percentile": 227.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 227.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 188.96, "90th_percentile": 188.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 188.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 222.32, "90th_percentile": 222.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 222.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 918.68, "90th_percentile": 1221.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 918.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5372", "type": "APC" } ], "description": "Level 2 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 625.22, "90th_percentile": 625.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 625.22, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 13505.66, "90th_percentile": 13505.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13505.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3943.0, "90th_percentile": 5571.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3943.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 236.21, "90th_percentile": 236.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 236.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 3840.57, "90th_percentile": 3840.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3840.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1496.81, "90th_percentile": 1496.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1496.81, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14828.99, "90th_percentile": 14828.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14828.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 325.79, "90th_percentile": 325.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 325.79, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 633.31, "90th_percentile": 633.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 633.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24087.71, "90th_percentile": 24087.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24087.71, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1605.7, "90th_percentile": 1605.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1605.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5188.27, "90th_percentile": 5188.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5188.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5373", "type": "APC" } ], "description": "Level 3 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 7602.43, "90th_percentile": 24309.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16528.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1545.49, "90th_percentile": 1920.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 1912.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 18770.61, "90th_percentile": 18770.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18770.61, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1886.69, "90th_percentile": 2432.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1886.69, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7844.88, "90th_percentile": 13809.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 9206.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1278.04, "90th_percentile": 4463.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1429.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1530.39, "90th_percentile": 1920.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 1671.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 8187.11, "90th_percentile": 10692.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9139.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3323.62, "90th_percentile": 3323.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3323.62, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5579.15, "90th_percentile": 5579.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5579.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2097.98, "90th_percentile": 2272.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2097.98, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 9177.18, "90th_percentile": 19765.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13026.43, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 40670.01, "90th_percentile": 40670.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40670.01, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1851.0, "90th_percentile": 1952.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1952.03, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1335.61, "90th_percentile": 3050.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1883.69, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1530.39, "90th_percentile": 2101.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 1912.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9295.67, "90th_percentile": 14061.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9904.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 9388.52, "90th_percentile": 9388.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9388.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1912.99, "90th_percentile": 1912.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1912.99, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 1912.99, "90th_percentile": 1912.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1912.99, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1335.61, "90th_percentile": 3370.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1412.61, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1591.61, "90th_percentile": 1591.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1591.61, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15055.81, "90th_percentile": 23744.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16564.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1192.74, "90th_percentile": 2571.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1789.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1525.42, "90th_percentile": 1938.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 1662.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8888.61, "90th_percentile": 20023.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 12291.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5374", "type": "APC" } ], "description": "Level 4 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 11323.17, "90th_percentile": 26864.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 16478.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2847.34, "90th_percentile": 3233.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "69", "median_amount": 3223.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 13221.47, "90th_percentile": 17213.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13221.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 3100.12, "90th_percentile": 3100.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3100.12, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5287.2, "90th_percentile": 5287.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5287.2, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13025.05, "90th_percentile": 22175.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "120", "median_amount": 15689.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1429.52, "90th_percentile": 1429.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1429.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2833.69, "90th_percentile": 3226.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 3110.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 23533.5, "90th_percentile": 23533.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23533.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 4787.68, "90th_percentile": 9716.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5933.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3263.4, "90th_percentile": 6331.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6166.46, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7787.85, "90th_percentile": 7787.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7787.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1496.81, "90th_percentile": 4615.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 3457.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19848.7, "90th_percentile": 24552.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22405.56, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 11791.49, "90th_percentile": 27322.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 17269.08, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 3286.52, "90th_percentile": 3286.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3286.52, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 2651.67, "90th_percentile": 3956.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2825.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2730.79, "90th_percentile": 3230.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 3220.79, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12432.56, "90th_percentile": 25316.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 16424.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 7146.3, "90th_percentile": 8689.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8494.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2926.83, "90th_percentile": 3233.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 3227.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1493.92, "90th_percentile": 3138.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2651.67, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2616.39, "90th_percentile": 2616.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2616.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 23468.51, "90th_percentile": 23525.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23468.51, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11612.05, "90th_percentile": 20662.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 14860.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1266.53, "90th_percentile": 3850.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 2124.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2602.4, "90th_percentile": 3262.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 3253.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9954.37, "90th_percentile": 20343.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 13917.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5375", "type": "APC" } ], "description": "Level 5 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 15004.91, "90th_percentile": 27255.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 20059.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3798.1, "90th_percentile": 4756.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 4751.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 18452.13, "90th_percentile": 24389.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19739.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 4668.04, "90th_percentile": 4668.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4668.04, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3787.89, "90th_percentile": 3787.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3787.89, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19732.2, "90th_percentile": 24604.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "82", "median_amount": 20844.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 4709.13, "90th_percentile": 4875.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4709.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4443.5, "90th_percentile": 5398.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 4747.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 6788.07, "90th_percentile": 19698.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 10212.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 5406.2, "90th_percentile": 9992.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5844.45, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5139.5, "90th_percentile": 5139.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5139.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2971.7, "90th_percentile": 6350.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 4613.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 42170.08, "90th_percentile": 42170.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42170.08, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 20174.83, "90th_percentile": 30106.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25348.25, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 4421.24, "90th_percentile": 4844.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4844.18, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3547.11, "90th_percentile": 6155.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4649.15, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4296.5, "90th_percentile": 4757.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 4749.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15731.69, "90th_percentile": 31688.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 20486.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 9715.76, "90th_percentile": 21920.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11096.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 4624.43, "90th_percentile": 4754.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 4754.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3585.7, "90th_percentile": 5666.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5320.66, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3950.32, "90th_percentile": 3950.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3950.32, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 37282.08, "90th_percentile": 55828.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37282.08, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18775.89, "90th_percentile": 21682.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 20550.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 3900.97, "90th_percentile": 5915.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5189.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3835.82, "90th_percentile": 4803.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 4654.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 16065.65, "90th_percentile": 21781.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 20085.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5376", "type": "APC" } ], "description": "Level 6 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 31289.11, "90th_percentile": 59925.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36482.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6909.08, "90th_percentile": 8871.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 8642.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 24095.79, "90th_percentile": 24095.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24095.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 28998.46, "90th_percentile": 45456.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 38216.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 7447.03, "90th_percentile": 7447.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7447.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8248.28, "90th_percentile": 8248.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8248.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 13487.02, "90th_percentile": 13487.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13487.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 46.15, "90th_percentile": 46.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46.15, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 9997.65, "90th_percentile": 9997.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9997.65, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 55349.05, "90th_percentile": 55349.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 55349.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 31102.49, "90th_percentile": 32466.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31669.87, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 8811.61, "90th_percentile": 8811.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8811.61, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7056.75, "90th_percentile": 8838.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 8212.45, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18384.65, "90th_percentile": 43862.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33896.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 18082.48, "90th_percentile": 18082.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18082.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 8642.17, "90th_percentile": 8646.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8642.17, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8431.77, "90th_percentile": 8431.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8431.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21727.18, "90th_percentile": 34867.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21930.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8728.24, "90th_percentile": 9002.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8728.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 25735.65, "90th_percentile": 28396.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25735.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5377", "type": "APC" } ], "description": "Level 7 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 42477.36, "90th_percentile": 42477.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42477.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12142.77, "90th_percentile": 12142.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12142.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 18548.35, "90th_percentile": 18548.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18548.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31170.37, "90th_percentile": 31170.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31170.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12262.29, "90th_percentile": 12262.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12262.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5378", "type": "APC" } ], "description": "Level 8 Urology and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 22348.19, "90th_percentile": 22348.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22348.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18796.89, "90th_percentile": 18806.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18803.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63079.0, "90th_percentile": 71851.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66965.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15037.51, "90th_percentile": 18802.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18517.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 22939.47, "90th_percentile": 22939.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22939.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 15182.5, "90th_percentile": 15182.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15182.5, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3157.22, "90th_percentile": 3157.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3157.22, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 17622.54, "90th_percentile": 17622.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17622.54, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15066.48, "90th_percentile": 15066.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15066.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 18630.5, "90th_percentile": 18630.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18630.5, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18346.09, "90th_percentile": 18806.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18346.09, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 45752.84, "90th_percentile": 61811.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45752.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 18581.59, "90th_percentile": 18581.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18581.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15724.73, "90th_percentile": 16263.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15724.73, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 19746.74, "90th_percentile": 19746.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19746.74, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 60108.8, "90th_percentile": 60108.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 60108.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 14919.94, "90th_percentile": 14919.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14919.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15187.89, "90th_percentile": 18987.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18725.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 43352.01, "90th_percentile": 50819.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47944.99, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5401", "type": "APC" } ], "description": "Dialysis", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 10012.75, "90th_percentile": 10012.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10012.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 1002.31, "90th_percentile": 1002.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1002.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1316.04, "90th_percentile": 4262.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 2283.9, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2141.87, "90th_percentile": 2141.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2141.87, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1055.94, "90th_percentile": 1382.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1350.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1304.0, "90th_percentile": 5000.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2605.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1451.62, "90th_percentile": 2582.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1607.71, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1137.6, "90th_percentile": 4332.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1825.34, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 16128.54, "90th_percentile": 16128.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16128.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 3344.93, "90th_percentile": 3344.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3344.93, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1880.92, "90th_percentile": 1880.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1880.92, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 966.74, "90th_percentile": 7697.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2459.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2572.57, "90th_percentile": 2572.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2572.57, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1720.9, "90th_percentile": 2284.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1720.9, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 733.22, "90th_percentile": 2061.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 885.09, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2002.47, "90th_percentile": 18397.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2560.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12061.75, "90th_percentile": 12061.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12061.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5411", "type": "APC" } ], "description": "Level 1 Gynecologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 378.1, "90th_percentile": 1093.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 546.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 546.98, "90th_percentile": 1008.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 546.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 208.34, "90th_percentile": 216.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 216.64, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 381.02, "90th_percentile": 952.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 476.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 199.36, "90th_percentile": 207.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 207.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 164.35, "90th_percentile": 164.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 164.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 186.76, "90th_percentile": 282.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 216.64, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 179.6, "90th_percentile": 209.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "47", "median_amount": 186.76, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 233.48, "90th_percentile": 242.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "159", "median_amount": 242.79, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 635.68, "90th_percentile": 1297.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 635.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 508.73, "90th_percentile": 583.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 508.73, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 208.34, "90th_percentile": 216.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "58", "median_amount": 216.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 463.18, "90th_percentile": 966.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 483.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 287.76, "90th_percentile": 287.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 287.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 208.34, "90th_percentile": 216.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "92", "median_amount": 216.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 394.13, "90th_percentile": 985.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 492.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 205.44, "90th_percentile": 308.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 205.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 164.35, "90th_percentile": 164.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 164.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 216.64, "90th_percentile": 1070.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 535.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5412", "type": "APC" } ], "description": "Level 2 Gynecologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3488.68, "90th_percentile": 11917.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11808.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1321.68, "90th_percentile": 1321.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1321.68, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2877.27, "90th_percentile": 5571.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 3943.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 245.55, "90th_percentile": 245.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 245.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 3968.69, "90th_percentile": 3968.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3968.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1550.47, "90th_percentile": 1550.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1550.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 223.93, "90th_percentile": 1772.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 287.59, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10542.97, "90th_percentile": 10542.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10542.97, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 10470.06, "90th_percentile": 15758.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10540.01, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10514.7, "90th_percentile": 19583.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10560.72, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 110.88, "90th_percentile": 110.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 110.88, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11882.65, "90th_percentile": 11882.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11882.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1498.68, "90th_percentile": 1498.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1498.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11459.51, "90th_percentile": 14823.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12955.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5413", "type": "APC" } ], "description": "Level 3 Gynecologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 9986.38, "90th_percentile": 9986.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9986.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1438.64, "90th_percentile": 1438.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1438.64, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2971.2, "90th_percentile": 7756.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3714.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 822.02, "90th_percentile": 822.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 822.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 276.55, "90th_percentile": 276.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 276.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 13886.14, "90th_percentile": 13886.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13886.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14538.58, "90th_percentile": 14538.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14538.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5162.64, "90th_percentile": 13438.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8657.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1481.72, "90th_percentile": 1481.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1481.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6423.54, "90th_percentile": 6423.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6423.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5414", "type": "APC" } ], "description": "Level 4 Gynecologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 10308.94, "90th_percentile": 22415.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "79", "median_amount": 15373.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2790.63, "90th_percentile": 2977.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 2973.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 11824.67, "90th_percentile": 22678.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 15427.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 3094.94, "90th_percentile": 3094.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3094.94, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1724.9, "90th_percentile": 2290.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2052.04, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6667.9, "90th_percentile": 11063.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "192", "median_amount": 9206.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1963.59, "90th_percentile": 2041.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 2041.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2375.63, "90th_percentile": 2978.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 2969.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9206.0, "90th_percentile": 9206.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9206.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 3215.49, "90th_percentile": 11490.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 7771.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 2060.36, "90th_percentile": 4559.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 3893.44, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7215.72, "90th_percentile": 7215.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7215.72, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1933.07, "90th_percentile": 4000.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "74", "median_amount": 2391.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12292.17, "90th_percentile": 23069.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 20753.12, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 12737.17, "90th_percentile": 25144.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 17371.65, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 2481.27, "90th_percentile": 3030.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2483.7, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1769.59, "90th_percentile": 4267.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 2133.95, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2375.34, "90th_percentile": 2979.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 2518.86, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12118.15, "90th_percentile": 20571.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 16278.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 5915.52, "90th_percentile": 8932.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7461.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2635.97, "90th_percentile": 2977.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2975.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21177.39, "90th_percentile": 28963.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21177.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1840.22, "90th_percentile": 3569.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 2133.95, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2470.35, "90th_percentile": 2471.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2470.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21105.6, "90th_percentile": 26064.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21105.6, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9230.69, "90th_percentile": 18801.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 14383.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1745.04, "90th_percentile": 2834.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 2023.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2399.1, "90th_percentile": 3008.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 2811.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9677.84, "90th_percentile": 21522.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "148", "median_amount": 15434.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5415", "type": "APC" } ], "description": "Level 5 Gynecologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 16315.93, "90th_percentile": 53457.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 22681.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4617.81, "90th_percentile": 9533.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 7994.05, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 17720.13, "90th_percentile": 22517.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17720.13, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2712.85, "90th_percentile": 2712.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2712.85, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16657.68, "90th_percentile": 30001.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "84", "median_amount": 20001.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 4257.72, "90th_percentile": 23378.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18411.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4150.45, "90th_percentile": 15330.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 4621.61, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2488.13, "90th_percentile": 67928.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3152.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 7420.11, "90th_percentile": 12927.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7420.11, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 14498.85, "90th_percentile": 14498.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14498.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2391.49, "90th_percentile": 6207.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 2964.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3725.03, "90th_percentile": 3725.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3725.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20226.22, "90th_percentile": 64266.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25439.61, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 16594.68, "90th_percentile": 84945.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 29301.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 4415.37, "90th_percentile": 4415.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4415.37, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3839.75, "90th_percentile": 3839.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3839.75, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4609.86, "90th_percentile": 9135.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7359.88, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15162.34, "90th_percentile": 52106.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 25694.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 12313.66, "90th_percentile": 16403.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12313.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 8724.14, "90th_percentile": 9252.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8724.14, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31670.3, "90th_percentile": 31670.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31670.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1430.05, "90th_percentile": 3983.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2256.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 26478.14, "90th_percentile": 58307.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 52752.35, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11901.29, "90th_percentile": 22568.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 19755.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 3777.82, "90th_percentile": 3777.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3777.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4249.27, "90th_percentile": 9051.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6165.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14925.43, "90th_percentile": 24009.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 20562.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5416", "type": "APC" } ], "description": "Level 6 Gynecologic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 39907.99, "90th_percentile": 39907.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39907.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6916.43, "90th_percentile": 8871.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6939.47, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44821.76, "90th_percentile": 53216.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48501.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2670.8, "90th_percentile": 2670.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2670.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6597.48, "90th_percentile": 10574.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6735.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 22016.18, "90th_percentile": 22016.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22016.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 8913.81, "90th_percentile": 8913.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8913.81, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16382.12, "90th_percentile": 16382.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16382.12, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 5285.5, "90th_percentile": 5285.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5285.5, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 57275.28, "90th_percentile": 57275.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57275.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 4704.44, "90th_percentile": 4704.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4704.44, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 58147.96, "90th_percentile": 58147.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58147.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 23443.03, "90th_percentile": 23443.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23443.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3615.69, "90th_percentile": 3615.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3615.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 22187.72, "90th_percentile": 22187.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22187.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6803.03, "90th_percentile": 6974.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6803.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20371.7, "90th_percentile": 20371.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20371.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5431", "type": "APC" } ], "description": "Level 1 Nerve Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 7101.38, "90th_percentile": 19242.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 13836.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1458.86, "90th_percentile": 1830.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 1723.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 11057.65, "90th_percentile": 19575.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18083.34, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1062.41, "90th_percentile": 1062.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1062.41, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9205.98, "90th_percentile": 23468.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "60", "median_amount": 21637.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1016.62, "90th_percentile": 1306.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1016.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1458.86, "90th_percentile": 2741.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 1829.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 3599.38, "90th_percentile": 6788.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4014.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1977.4, "90th_percentile": 4612.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3115.06, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8031.14, "90th_percentile": 8031.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8031.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 793.75, "90th_percentile": 1530.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 1190.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1473.45, "90th_percentile": 1473.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1473.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 21678.68, "90th_percentile": 24548.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21678.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 11866.54, "90th_percentile": 20489.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14396.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1310.79, "90th_percentile": 1860.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1365.79, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1021.64, "90th_percentile": 1062.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1062.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1372.77, "90th_percentile": 1832.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 1622.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7054.19, "90th_percentile": 19363.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 14084.69, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2286.42, "90th_percentile": 11836.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9098.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1490.37, "90th_percentile": 1830.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1558.38, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1062.41, "90th_percentile": 1365.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1062.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1517.22, "90th_percentile": 1517.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1517.22, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24741.37, "90th_percentile": 24741.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24741.37, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6825.76, "90th_percentile": 22586.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13911.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 671.64, "90th_percentile": 2732.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1007.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1473.45, "90th_percentile": 1849.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 1823.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8420.75, "90th_percentile": 18677.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 13593.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5432", "type": "APC" } ], "description": "Level 2 Nerve Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17006.51, "90th_percentile": 17006.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17006.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7421.27, "90th_percentile": 7421.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7421.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 3042.53, "90th_percentile": 3042.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3042.53, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 16609.51, "90th_percentile": 16609.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16609.51, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7321.09, "90th_percentile": 7321.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7321.09, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5574.69, "90th_percentile": 5574.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5574.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5441", "type": "APC" } ], "description": "Level 1 Nerve Injections", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1723.56, "90th_percentile": 1723.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1723.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 269.16, "90th_percentile": 666.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 276.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 371.57, "90th_percentile": 371.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 371.57, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3244.35, "90th_percentile": 6763.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3614.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 289.71, "90th_percentile": 289.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 289.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 246.26, "90th_percentile": 263.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 246.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 868.27, "90th_percentile": 868.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 868.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 245.3, "90th_percentile": 518.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 245.3, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 814.76, "90th_percentile": 814.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 814.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 275.66, "90th_percentile": 275.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 275.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 375.77, "90th_percentile": 5311.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 375.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 1261.3, "90th_percentile": 1261.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1261.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 250.74, "90th_percentile": 250.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 250.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 357.3, "90th_percentile": 357.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 357.3, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 344.04, "90th_percentile": 490.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 344.04, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 278.42, "90th_percentile": 278.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 278.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1225.6, "90th_percentile": 4787.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1893.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5442", "type": "APC" } ], "description": "Level 2 Nerve Injections", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3808.08, "90th_percentile": 11374.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "71", "median_amount": 5236.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 492.71, "90th_percentile": 782.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "149", "median_amount": 647.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 4861.31, "90th_percentile": 8869.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6066.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 396.45, "90th_percentile": 708.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 708.27, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2760.07, "90th_percentile": 3943.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "207", "median_amount": 3714.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 569.04, "90th_percentile": 1730.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 677.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 404.9, "90th_percentile": 652.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 621.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1493.85, "90th_percentile": 2587.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 2330.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 341.77, "90th_percentile": 3055.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 610.58, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2637.1, "90th_percentile": 7348.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2637.1, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 444.3, "90th_percentile": 2495.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "92", "median_amount": 793.75, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 610.58, "90th_percentile": 610.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 610.58, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3369.9, "90th_percentile": 7170.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 6268.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 4290.83, "90th_percentile": 15718.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 5447.31, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 628.46, "90th_percentile": 1142.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 659.9, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 681.09, "90th_percentile": 1839.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 708.27, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 195.9, "90th_percentile": 980.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "83", "median_amount": 646.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3007.22, "90th_percentile": 11777.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 4847.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2185.31, "90th_percentile": 4631.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2856.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 313.5, "90th_percentile": 653.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 653.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6334.58, "90th_percentile": 6334.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6334.58, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 1857.28, "90th_percentile": 1857.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1857.28, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 396.45, "90th_percentile": 1050.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 708.27, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 538.06, "90th_percentile": 1533.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 538.06, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3350.17, "90th_percentile": 11440.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5872.02, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 679.04, "90th_percentile": 679.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 679.04, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3050.61, "90th_percentile": 14894.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 4659.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 645.87, "90th_percentile": 2304.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 671.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 359.17, "90th_percentile": 683.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "97", "median_amount": 628.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2975.82, "90th_percentile": 8471.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "118", "median_amount": 4703.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5443", "type": "APC" } ], "description": "Level 3 Nerve Injections", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1888.49, "90th_percentile": 10054.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "93", "median_amount": 4312.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 665.12, "90th_percentile": 1254.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "140", "median_amount": 974.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 2269.33, "90th_percentile": 10345.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 7749.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 691.71, "90th_percentile": 1013.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 691.71, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 681.09, "90th_percentile": 1062.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 708.27, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2970.58, "90th_percentile": 15640.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "238", "median_amount": 5571.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 677.74, "90th_percentile": 1016.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 843.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 532.46, "90th_percentile": 1547.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "82", "median_amount": 943.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 708.27, "90th_percentile": 5129.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 1694.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 610.58, "90th_percentile": 1025.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 915.87, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 793.75, "90th_percentile": 1190.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "94", "median_amount": 1144.94, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 994.92, "90th_percentile": 1007.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1007.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2920.74, "90th_percentile": 12972.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3012.33, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 2278.46, "90th_percentile": 10421.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 4520.24, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 5756.14, "90th_percentile": 5756.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5756.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 408.36, "90th_percentile": 1272.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 629.43, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 708.27, "90th_percentile": 1062.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 847.57, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 425.89, "90th_percentile": 1249.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "118", "median_amount": 840.59, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1965.25, "90th_percentile": 9342.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "66", "median_amount": 3540.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 1213.66, "90th_percentile": 5123.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 2061.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 498.19, "90th_percentile": 1073.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 838.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 708.27, "90th_percentile": 1593.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 1021.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 691.71, "90th_percentile": 1037.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 847.68, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4418.66, "90th_percentile": 11723.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4418.66, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 506.58, "90th_percentile": 506.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 506.58, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2118.13, "90th_percentile": 9544.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 3583.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 671.64, "90th_percentile": 1007.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 671.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 655.9, "90th_percentile": 1261.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "144", "median_amount": 852.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2142.01, "90th_percentile": 10060.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "191", "median_amount": 4257.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5461", "type": "APC" } ], "description": "Level 1 Neurostimulator and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 23084.55, "90th_percentile": 23084.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23084.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3303.49, "90th_percentile": 3303.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3303.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2671.96, "90th_percentile": 2671.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2671.96, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19915.75, "90th_percentile": 21541.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19915.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3223.24, "90th_percentile": 3223.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3223.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 51441.14, "90th_percentile": 51441.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51441.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 15830.66, "90th_percentile": 15830.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15830.66, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2964.22, "90th_percentile": 2964.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2964.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 3218.29, "90th_percentile": 3218.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3218.29, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2714.88, "90th_percentile": 2714.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2714.88, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18779.7, "90th_percentile": 18779.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18779.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2594.88, "90th_percentile": 3058.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2836.91, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20158.88, "90th_percentile": 20158.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20158.88, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5462", "type": "APC" } ], "description": "Level 2 Neurostimulator and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 26281.82, "90th_percentile": 35326.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26281.82, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6097.23, "90th_percentile": 7021.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 6133.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16141.6, "90th_percentile": 38216.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24842.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5824.91, "90th_percentile": 11953.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6096.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 13288.9, "90th_percentile": 13288.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13288.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 5931.55, "90th_percentile": 5931.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5931.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4952.0, "90th_percentile": 4952.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4952.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 10346.35, "90th_percentile": 10346.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10346.35, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 10048.59, "90th_percentile": 10048.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10048.59, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5677.91, "90th_percentile": 6137.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5838.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17281.45, "90th_percentile": 37631.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25939.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 29133.7, "90th_percentile": 29133.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29133.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 5019.0, "90th_percentile": 5019.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5019.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4952.0, "90th_percentile": 6215.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5822.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8284.15, "90th_percentile": 31674.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12026.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5463", "type": "APC" } ], "description": "Level 3 Neurostimulator and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9316.24, "90th_percentile": 9316.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9316.24, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 45882.99, "90th_percentile": 45882.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45882.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1021.66, "90th_percentile": 1021.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1021.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 12135.63, "90th_percentile": 12135.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12135.63, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11651.8, "90th_percentile": 11651.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11651.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11761.76, "90th_percentile": 11764.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11761.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5464", "type": "APC" } ], "description": "Level 4 Neurostimulator and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 54150.07, "90th_percentile": 84949.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 82730.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19486.3, "90th_percentile": 20042.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 19752.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63079.0, "90th_percentile": 82187.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 70923.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 22097.46, "90th_percentile": 22097.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22097.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19721.87, "90th_percentile": 20033.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 20031.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 9440.52, "90th_percentile": 25936.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23154.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 26912.87, "90th_percentile": 28394.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27779.37, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18217.63, "90th_percentile": 18217.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18217.63, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 46028.51, "90th_percentile": 46028.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46028.51, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 77417.33, "90th_percentile": 78908.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77417.33, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 20434.36, "90th_percentile": 20434.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20434.36, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 10.44, "90th_percentile": 10.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10.44, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19489.8, "90th_percentile": 20034.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 19633.67, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 35964.45, "90th_percentile": 82528.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 39500.09, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 30417.07, "90th_percentile": 30417.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30417.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 19742.47, "90th_percentile": 19742.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19742.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24014.56, "90th_percentile": 24014.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24014.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18217.63, "90th_percentile": 18217.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18217.63, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 44383.71, "90th_percentile": 44383.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44383.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 22772.43, "90th_percentile": 22772.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22772.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16180.74, "90th_percentile": 20268.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 19829.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 37053.4, "90th_percentile": 62092.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40224.94, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5465", "type": "APC" } ], "description": "Level 5 Neurostimulator and Related Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8478.68, "90th_percentile": 89023.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75074.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22766.01, "90th_percentile": 28475.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 28275.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 75558.28, "90th_percentile": 75558.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75558.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24014.56, "90th_percentile": 24014.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24014.56, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60869.58, "90th_percentile": 82187.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 63079.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22766.01, "90th_percentile": 28463.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 28153.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 41180.99, "90th_percentile": 41180.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41180.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 7000.03, "90th_percentile": 7000.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7000.03, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 25879.91, "90th_percentile": 26912.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 26912.87, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 102760.86, "90th_percentile": 102760.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 102760.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 71942.21, "90th_percentile": 101741.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75724.17, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 28643.28, "90th_percentile": 29038.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28778.28, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 24014.56, "90th_percentile": 24014.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24014.56, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22766.01, "90th_percentile": 28467.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 28006.71, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 68791.5, "90th_percentile": 89975.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 72693.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 27642.22, "90th_percentile": 28464.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27662.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24014.56, "90th_percentile": 24014.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24014.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 93021.06, "90th_percentile": 93021.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 93021.06, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 29890.39, "90th_percentile": 29890.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29890.39, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 63417.2, "90th_percentile": 65755.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 63491.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 22772.43, "90th_percentile": 22772.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22772.43, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 22977.45, "90th_percentile": 28748.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 27932.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 58747.62, "90th_percentile": 65831.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 63436.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5471", "type": "APC" } ], "description": "Implantation of Drug Infusion Device", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16201.04, "90th_percentile": 16366.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16201.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 16512.03, "90th_percentile": 16512.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16512.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16669.89, "90th_percentile": 16669.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16669.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5493", "type": "APC" } ], "description": "Level 3 Intraocular Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 3868.72, "90th_percentile": 3868.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3868.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5503", "type": "APC" } ], "description": "Level 3 Extraocular, Repair, and Plastic Eye Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2087.45, "90th_percentile": 2087.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2087.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 13809.0, "90th_percentile": 19909.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13809.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2619.76, "90th_percentile": 4428.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3480.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1817.53, "90th_percentile": 3707.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2184.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 3637.37, "90th_percentile": 7318.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3637.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 2895.58, "90th_percentile": 2895.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2895.58, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 3919.89, "90th_percentile": 3919.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3919.89, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2188.62, "90th_percentile": 2188.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2188.62, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 12772.25, "90th_percentile": 12772.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12772.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1845.41, "90th_percentile": 1845.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1845.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1916.97, "90th_percentile": 1916.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1916.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1813.83, "90th_percentile": 1813.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1813.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3497.75, "90th_percentile": 3497.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3497.75, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2209.38, "90th_percentile": 2209.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2209.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15049.97, "90th_percentile": 19882.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15049.97, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5504", "type": "APC" } ], "description": "Level 4 Extraocular, Repair, and Plastic Eye Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 33931.07, "90th_percentile": 33931.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33931.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 6109.76, "90th_percentile": 6109.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6109.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 5580.92, "90th_percentile": 5580.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5580.92, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2717.57, "90th_percentile": 2717.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2717.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 2424.91, "90th_percentile": 2424.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2424.91, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3530.32, "90th_percentile": 3530.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3530.32, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 27036.92, "90th_percentile": 27036.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27036.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2845.39, "90th_percentile": 3571.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3556.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5521", "type": "APC" } ], "description": "Level 1 Imaging without Contrast", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 139.96, "90th_percentile": 1035.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "804", "median_amount": 247.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 144.31, "90th_percentile": 330.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 144.31, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 61.31, "90th_percentile": 171.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "991", "median_amount": 82.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 185.13, "90th_percentile": 1070.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "137", "median_amount": 302.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 30.76, "90th_percentile": 135.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 84.16, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 71.12, "90th_percentile": 219.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "154", "median_amount": 71.12, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 137.29, "90th_percentile": 901.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2225", "median_amount": 213.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 68.05, "90th_percentile": 153.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "176", "median_amount": 68.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 33.22, "90th_percentile": 86.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "542", "median_amount": 82.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 144.58, "90th_percentile": 302.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 144.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 82.85, "90th_percentile": 505.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "288", "median_amount": 116.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 61.31, "90th_percentile": 189.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "199", "median_amount": 68.67, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 110.52, "90th_percentile": 584.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 129.96, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 79.7, "90th_percentile": 246.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "816", "median_amount": 79.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 53.95, "90th_percentile": 155.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 66.43, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 190.31, "90th_percentile": 1346.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "94", "median_amount": 315.15, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 187.61, "90th_percentile": 1104.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "353", "median_amount": 417.62, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 109.07, "90th_percentile": 1388.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 569.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 8.9, "90th_percentile": 83.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "95", "median_amount": 76.4, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 163.15, "90th_percentile": 163.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 163.15, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 71.12, "90th_percentile": 211.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "182", "median_amount": 71.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 35.0, "90th_percentile": 171.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "654", "median_amount": 83.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 158.63, "90th_percentile": 992.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "767", "median_amount": 270.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 97.93, "90th_percentile": 540.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "98", "median_amount": 129.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 33.56, "90th_percentile": 127.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "221", "median_amount": 83.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 188.81, "90th_percentile": 226.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 188.81, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 83.22, "90th_percentile": 86.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83.22, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 71.12, "90th_percentile": 218.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "323", "median_amount": 71.12, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 53.95, "90th_percentile": 163.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "107", "median_amount": 68.41, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 117.45, "90th_percentile": 1917.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 302.58, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 37.34, "90th_percentile": 37.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37.34, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 158.17, "90th_percentile": 1012.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "497", "median_amount": 261.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 67.44, "90th_percentile": 208.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "194", "median_amount": 67.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 58.55, "90th_percentile": 173.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "836", "median_amount": 83.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 161.64, "90th_percentile": 1012.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1520", "median_amount": 249.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5522", "type": "APC" } ], "description": "Level 2 Imaging without Contrast", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 206.28, "90th_percentile": 981.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1957", "median_amount": 388.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 99.3, "90th_percentile": 99.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 99.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74.8, "90th_percentile": 200.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2681", "median_amount": 99.3, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 210.91, "90th_percentile": 1013.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "239", "median_amount": 444.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 44.0, "90th_percentile": 207.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 103.27, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 71.12, "90th_percentile": 310.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "407", "median_amount": 146.39, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 176.65, "90th_percentile": 980.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "4986", "median_amount": 357.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 68.05, "90th_percentile": 285.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "449", "median_amount": 140.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40.54, "90th_percentile": 200.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1369", "median_amount": 99.3, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 144.0, "90th_percentile": 3285.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 553.42, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 101.0, "90th_percentile": 479.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "546", "median_amount": 183.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 68.67, "90th_percentile": 288.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "560", "median_amount": 141.34, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 112.68, "90th_percentile": 551.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "56", "median_amount": 219.96, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 79.7, "90th_percentile": 348.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2331", "median_amount": 164.06, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 80.03, "90th_percentile": 198.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 100.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 275.0, "90th_percentile": 1534.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "178", "median_amount": 585.12, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 216.46, "90th_percentile": 1035.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "765", "median_amount": 446.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 210.14, "90th_percentile": 1089.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 403.72, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 26.33, "90th_percentile": 204.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "190", "median_amount": 101.33, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 107.63, "90th_percentile": 538.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 250.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 106.67, "90th_percentile": 292.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "481", "median_amount": 180.97, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 40.54, "90th_percentile": 200.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1839", "median_amount": 99.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 205.4, "90th_percentile": 1003.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1752", "median_amount": 402.42, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 114.31, "90th_percentile": 505.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "202", "median_amount": 232.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 42.17, "90th_percentile": 101.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "430", "median_amount": 99.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 330.87, "90th_percentile": 826.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 632.1, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 99.7, "90th_percentile": 1248.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 609.53, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 71.12, "90th_percentile": 310.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "955", "median_amount": 146.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 81.47, "90th_percentile": 175.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "171", "median_amount": 92.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 171.85, "90th_percentile": 1430.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 441.16, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 105.27, "90th_percentile": 105.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 105.27, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 198.45, "90th_percentile": 998.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1076", "median_amount": 383.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 67.44, "90th_percentile": 294.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "582", "median_amount": 138.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 75.79, "90th_percentile": 201.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1687", "median_amount": 100.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 202.22, "90th_percentile": 1060.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "3026", "median_amount": 426.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5523", "type": "APC" } ], "description": "Level 3 Imaging without Contrast", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 434.63, "90th_percentile": 1593.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "851", "median_amount": 1108.42, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 226.64, "90th_percentile": 226.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 226.64, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90.36, "90th_percentile": 328.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1229", "median_amount": 225.91, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 434.63, "90th_percentile": 1595.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "136", "median_amount": 1254.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 185.75, "90th_percentile": 239.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 234.75, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 146.39, "90th_percentile": 442.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "142", "median_amount": 281.31, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 378.44, "90th_percentile": 1557.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2178", "median_amount": 1099.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 140.08, "90th_percentile": 441.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "202", "median_amount": 306.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90.67, "90th_percentile": 286.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "634", "median_amount": 220.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 610.28, "90th_percentile": 1165.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 875.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 213.26, "90th_percentile": 782.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "222", "median_amount": 543.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 126.2, "90th_percentile": 335.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "192", "median_amount": 265.25, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 243.72, "90th_percentile": 712.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 445.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 164.06, "90th_percentile": 467.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "900", "median_amount": 348.05, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 182.38, "90th_percentile": 228.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 194.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 561.23, "90th_percentile": 2310.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "77", "median_amount": 1232.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 456.86, "90th_percentile": 1719.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "306", "median_amount": 1124.93, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 463.75, "90th_percentile": 2733.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 1376.07, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 30.33, "90th_percentile": 314.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "78", "median_amount": 210.33, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 917.8, "90th_percentile": 917.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 917.8, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 146.39, "90th_percentile": 493.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "209", "median_amount": 219.59, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90.3, "90th_percentile": 329.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "845", "median_amount": 225.72, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 440.05, "90th_percentile": 1705.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "749", "median_amount": 1230.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 240.34, "90th_percentile": 882.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "96", "median_amount": 605.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 89.22, "90th_percentile": 336.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "188", "median_amount": 225.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1318.5, "90th_percentile": 1977.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1318.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 226.72, "90th_percentile": 226.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 226.72, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 146.39, "90th_percentile": 426.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "381", "median_amount": 319.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 142.77, "90th_percentile": 359.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "71", "median_amount": 235.71, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 908.56, "90th_percentile": 1981.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 1435.0, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 240.01, "90th_percentile": 240.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 240.01, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 358.58, "90th_percentile": 1849.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "488", "median_amount": 1271.07, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 138.82, "90th_percentile": 467.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "238", "median_amount": 303.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 91.2, "90th_percentile": 330.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "763", "median_amount": 223.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 442.43, "90th_percentile": 1840.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1376", "median_amount": 1340.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5524", "type": "APC" } ], "description": "Level 4 Imaging without Contrast", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 986.11, "90th_percentile": 2768.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "320", "median_amount": 1545.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 190.75, "90th_percentile": 190.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 190.75, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 205.02, "90th_percentile": 633.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1059", "median_amount": 512.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 1236.75, "90th_percentile": 2786.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "63", "median_amount": 1570.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 213.87, "90th_percentile": 657.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 516.97, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 425.56, "90th_percentile": 700.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 442.54, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 904.58, "90th_percentile": 2408.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "934", "median_amount": 1346.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 258.85, "90th_percentile": 670.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 423.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 205.81, "90th_percentile": 638.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "378", "median_amount": 513.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1887.01, "90th_percentile": 1887.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1887.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 455.11, "90th_percentile": 1431.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "111", "median_amount": 758.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 252.4, "90th_percentile": 568.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 381.5, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 344.4, "90th_percentile": 866.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 860.05, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 410.15, "90th_percentile": 1006.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "180", "median_amount": 495.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 176.04, "90th_percentile": 1253.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 413.72, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1340.93, "90th_percentile": 3321.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "47", "median_amount": 2041.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1036.74, "90th_percentile": 2781.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "139", "median_amount": 1601.32, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 3384.93, "90th_percentile": 3384.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3384.93, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 58.99, "90th_percentile": 645.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 446.35, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 219.59, "90th_percentile": 673.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 442.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 204.81, "90th_percentile": 632.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "610", "median_amount": 514.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1009.69, "90th_percentile": 2643.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "303", "median_amount": 1565.2, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 812.05, "90th_percentile": 1602.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 854.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 205.01, "90th_percentile": 632.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "142", "median_amount": 512.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3667.61, "90th_percentile": 3667.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3667.61, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 2653.56, "90th_percentile": 2653.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2653.56, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 292.79, "90th_percentile": 621.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "92", "median_amount": 442.54, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 213.87, "90th_percentile": 536.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 426.01, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 649.01, "90th_percentile": 10020.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 1974.56, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 488.63, "90th_percentile": 488.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 488.63, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1058.55, "90th_percentile": 2693.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "190", "median_amount": 1550.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 403.55, "90th_percentile": 664.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 419.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 206.86, "90th_percentile": 641.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "445", "median_amount": 511.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1155.09, "90th_percentile": 2707.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "527", "median_amount": 1550.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5571", "type": "APC" } ], "description": "Level 1 Imaging with Contrast", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 503.05, "90th_percentile": 3860.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "301", "median_amount": 1660.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 136.91, "90th_percentile": 410.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "770", "median_amount": 281.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 637.54, "90th_percentile": 3953.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 2080.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 128.6, "90th_percentile": 292.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 169.03, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 474.2, "90th_percentile": 615.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 493.13, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 798.95, "90th_percentile": 3874.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "909", "median_amount": 2453.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 453.76, "90th_percentile": 543.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 471.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 102.54, "90th_percentile": 412.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "394", "median_amount": 200.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3271.51, "90th_percentile": 3271.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3271.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 243.47, "90th_percentile": 1599.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "134", "median_amount": 1110.07, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 409.79, "90th_percentile": 558.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 476.12, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 795.91, "90th_percentile": 1844.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 795.91, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 531.43, "90th_percentile": 636.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "190", "median_amount": 552.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 67.44, "90th_percentile": 1828.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 201.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 689.42, "90th_percentile": 3854.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 1651.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 591.16, "90th_percentile": 3376.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "163", "median_amount": 2153.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 1274.27, "90th_percentile": 3571.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1380.21, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 119.68, "90th_percentile": 414.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 214.63, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 474.2, "90th_percentile": 567.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 493.13, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 87.84, "90th_percentile": 412.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "392", "median_amount": 169.64, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 560.95, "90th_percentile": 3738.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "317", "median_amount": 1648.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 565.36, "90th_percentile": 1834.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 1564.44, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 67.7, "90th_percentile": 408.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "105", "median_amount": 307.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 267.93, "90th_percentile": 567.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "79", "median_amount": 493.13, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 170.87, "90th_percentile": 374.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 207.69, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 520.17, "90th_percentile": 4201.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1703.84, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 640.0, "90th_percentile": 4171.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "207", "median_amount": 2789.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 449.67, "90th_percentile": 538.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 467.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 73.02, "90th_percentile": 412.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "412", "median_amount": 283.01, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 760.56, "90th_percentile": 4171.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "562", "median_amount": 1746.53, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5572", "type": "APC" } ], "description": "Level 2 Imaging with Contrast", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1202.09, "90th_percentile": 2960.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "527", "median_amount": 2011.03, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 136.12, "90th_percentile": 620.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1015", "median_amount": 334.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 1646.9, "90th_percentile": 3540.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "78", "median_amount": 2043.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 52.84, "90th_percentile": 352.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 277.48, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 474.2, "90th_percentile": 493.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "67", "median_amount": 483.52, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1154.71, "90th_percentile": 3084.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1390", "median_amount": 1987.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 453.76, "90th_percentile": 543.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "85", "median_amount": 462.68, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 74.12, "90th_percentile": 533.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "552", "median_amount": 333.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 462.68, "90th_percentile": 1061.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "152", "median_amount": 855.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 416.83, "90th_percentile": 544.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "66", "median_amount": 425.11, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 666.32, "90th_percentile": 1269.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 980.33, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 524.72, "90th_percentile": 636.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "335", "median_amount": 541.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 117.76, "90th_percentile": 645.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 338.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1282.24, "90th_percentile": 4354.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 2274.78, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1178.39, "90th_percentile": 2520.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "227", "median_amount": 1837.17, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 1416.03, "90th_percentile": 2455.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2050.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 139.8, "90th_percentile": 463.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "66", "median_amount": 340.31, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 550.6, "90th_percentile": 550.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 550.6, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 464.97, "90th_percentile": 493.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "81", "median_amount": 483.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15.0, "90th_percentile": 508.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "670", "median_amount": 333.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1261.05, "90th_percentile": 3297.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "513", "median_amount": 1971.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 641.53, "90th_percentile": 1105.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "82", "median_amount": 928.96, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 135.4, "90th_percentile": 623.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "165", "median_amount": 335.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 474.2, "90th_percentile": 567.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "122", "median_amount": 483.52, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 295.18, "90th_percentile": 664.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 348.26, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 714.61, "90th_percentile": 3674.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 2132.82, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 408.37, "90th_percentile": 408.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 408.37, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1270.08, "90th_percentile": 3855.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "350", "median_amount": 2190.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 449.67, "90th_percentile": 542.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "105", "median_amount": 467.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 138.88, "90th_percentile": 549.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "545", "median_amount": 336.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1381.96, "90th_percentile": 3016.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "894", "median_amount": 2192.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5573", "type": "APC" } ], "description": "Level 3 Imaging with Contrast", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1456.14, "90th_percentile": 7277.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "62", "median_amount": 1677.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 361.91, "90th_percentile": 2487.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "210", "median_amount": 832.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 1803.83, "90th_percentile": 15863.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6439.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 125.16, "90th_percentile": 125.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 125.16, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 442.54, "90th_percentile": 673.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 442.54, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1076.86, "90th_percentile": 5016.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "175", "median_amount": 1387.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 423.47, "90th_percentile": 1302.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 423.47, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 296.12, "90th_percentile": 2475.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "101", "median_amount": 765.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 736.85, "90th_percentile": 2352.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 758.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 366.86, "90th_percentile": 3901.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1419.33, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 598.06, "90th_percentile": 916.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 916.42, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 495.95, "90th_percentile": 2746.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 706.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2560.03, "90th_percentile": 2560.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2560.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2244.1, "90th_percentile": 31637.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8847.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1567.61, "90th_percentile": 16841.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 1807.79, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 552.85, "90th_percentile": 961.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 727.63, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 442.54, "90th_percentile": 2710.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 442.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 297.72, "90th_percentile": 2130.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "140", "median_amount": 830.81, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1127.15, "90th_percentile": 13006.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 2237.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 881.26, "90th_percentile": 52580.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 891.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 720.02, "90th_percentile": 2486.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 830.97, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2264.66, "90th_percentile": 2264.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2264.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 2641.14, "90th_percentile": 2641.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2641.14, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 442.54, "90th_percentile": 3278.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 628.47, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 613.84, "90th_percentile": 2972.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 713.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2058.77, "90th_percentile": 2058.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2058.77, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1591.46, "90th_percentile": 9059.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 1670.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 419.65, "90th_percentile": 2061.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 468.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 392.13, "90th_percentile": 2378.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "125", "median_amount": 748.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1471.83, "90th_percentile": 5451.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "80", "median_amount": 1663.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5591", "type": "APC" } ], "description": "Level 1 Nuclear Medicine and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1554.86, "90th_percentile": 2360.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 2111.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 317.25, "90th_percentile": 782.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "69", "median_amount": 379.14, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 2111.21, "90th_percentile": 2360.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2111.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 818.86, "90th_percentile": 818.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 818.86, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 389.93, "90th_percentile": 389.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 389.93, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1130.85, "90th_percentile": 1897.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "100", "median_amount": 1332.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 373.13, "90th_percentile": 1065.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 536.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 371.21, "90th_percentile": 787.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 625.26, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 728.91, "90th_percentile": 1069.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 728.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 376.49, "90th_percentile": 404.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 376.49, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1183.86, "90th_percentile": 1183.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1183.86, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 437.0, "90th_percentile": 771.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 741.55, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 303.19, "90th_percentile": 303.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 303.19, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2020.12, "90th_percentile": 5874.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2790.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1506.41, "90th_percentile": 2189.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 1648.8, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 283.89, "90th_percentile": 787.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 487.58, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 389.93, "90th_percentile": 1113.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 389.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 105.0, "90th_percentile": 788.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 376.77, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1462.45, "90th_percentile": 2517.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 2137.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 859.77, "90th_percentile": 859.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 859.77, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 560.23, "90th_percentile": 617.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 586.93, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 389.93, "90th_percentile": 821.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 389.93, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1565.06, "90th_percentile": 2501.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 2181.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 369.77, "90th_percentile": 652.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 369.77, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 296.79, "90th_percentile": 789.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 383.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1613.59, "90th_percentile": 4222.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "59", "median_amount": 2315.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5592", "type": "APC" } ], "description": "Level 2 Nuclear Medicine and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1467.06, "90th_percentile": 4012.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2323.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 478.16, "90th_percentile": 507.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 501.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 759.87, "90th_percentile": 2058.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 1997.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 198.86, "90th_percentile": 623.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 508.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1125.81, "90th_percentile": 1311.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1186.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 778.16, "90th_percentile": 778.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 778.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 437.0, "90th_percentile": 449.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 437.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1422.94, "90th_percentile": 3126.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1422.94, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1831.05, "90th_percentile": 2448.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2326.67, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 389.93, "90th_percentile": 389.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 389.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 179.26, "90th_percentile": 512.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 502.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1286.53, "90th_percentile": 4227.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2321.34, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 1289.22, "90th_percentile": 2213.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1303.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 506.16, "90th_percentile": 506.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 506.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 593.31, "90th_percentile": 593.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 593.31, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3157.61, "90th_percentile": 4096.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3522.73, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 653.39, "90th_percentile": 653.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 653.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 341.09, "90th_percentile": 593.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 490.39, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2112.55, "90th_percentile": 4452.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 3465.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5593", "type": "APC" } ], "description": "Level 3 Nuclear Medicine and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3327.02, "90th_percentile": 6429.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "55", "median_amount": 4173.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1082.61, "90th_percentile": 2568.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "247", "median_amount": 1223.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 3597.07, "90th_percentile": 5682.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4198.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 1440.31, "90th_percentile": 2035.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1440.31, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1070.29, "90th_percentile": 2294.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1248.96, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2266.75, "90th_percentile": 4869.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "143", "median_amount": 3523.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1195.12, "90th_percentile": 4711.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1312.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 915.31, "90th_percentile": 1965.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "126", "median_amount": 1225.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2726.95, "90th_percentile": 2726.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2726.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1351.98, "90th_percentile": 2791.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 1985.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1035.36, "90th_percentile": 1205.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1074.63, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2450.45, "90th_percentile": 2450.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2450.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1345.97, "90th_percentile": 1871.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 1399.7, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 985.04, "90th_percentile": 985.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 985.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3111.39, "90th_percentile": 5294.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 4534.26, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 3639.62, "90th_percentile": 4906.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 4144.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 4540.3, "90th_percentile": 4540.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4540.3, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 988.99, "90th_percentile": 1290.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 1093.99, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1201.02, "90th_percentile": 1254.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1248.96, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 892.21, "90th_percentile": 1743.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "142", "median_amount": 1219.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1984.41, "90th_percentile": 6955.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "56", "median_amount": 3998.12, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 500.0, "90th_percentile": 3996.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 1773.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1084.26, "90th_percentile": 2582.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 1221.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1113.01, "90th_percentile": 2338.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1248.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1014.3, "90th_percentile": 1994.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1014.3, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6689.56, "90th_percentile": 6689.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6689.56, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 1204.33, "90th_percentile": 1204.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1204.33, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2855.78, "90th_percentile": 8009.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 6303.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1055.44, "90th_percentile": 1184.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1138.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 985.04, "90th_percentile": 2182.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "119", "median_amount": 1234.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2908.87, "90th_percentile": 7953.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "107", "median_amount": 6400.42, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5594", "type": "APC" } ], "description": "Level 4 Nuclear Medicine and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 4733.77, "90th_percentile": 12619.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "55", "median_amount": 5293.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1241.61, "90th_percentile": 6075.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "169", "median_amount": 1363.2, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 4234.47, "90th_percentile": 14391.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5156.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 1353.58, "90th_percentile": 1416.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1353.58, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1466.07, "90th_percentile": 1466.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1466.07, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3695.58, "90th_percentile": 12839.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "135", "median_amount": 4410.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1402.87, "90th_percentile": 1402.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1402.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1058.29, "90th_percentile": 6194.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "86", "median_amount": 1363.1, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1651.96, "90th_percentile": 4725.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 2411.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1215.34, "90th_percentile": 1415.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1263.85, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2891.52, "90th_percentile": 2891.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2891.52, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1579.94, "90th_percentile": 1643.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 1643.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1375.71, "90th_percentile": 1375.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1375.71, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5488.47, "90th_percentile": 18583.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6684.56, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 3220.19, "90th_percentile": 13207.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 5245.05, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 3220.19, "90th_percentile": 3220.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3220.19, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1196.73, "90th_percentile": 5224.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1389.89, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1409.79, "90th_percentile": 1466.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1466.07, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1043.59, "90th_percentile": 5571.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "128", "median_amount": 1362.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4696.19, "90th_percentile": 6264.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 5145.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 1994.4, "90th_percentile": 6840.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2819.24, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1239.59, "90th_percentile": 3871.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 1365.59, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1409.79, "90th_percentile": 1466.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 1466.07, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1133.26, "90th_percentile": 1159.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1146.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7877.74, "90th_percentile": 7877.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7877.74, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5068.37, "90th_percentile": 11762.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 6062.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1390.24, "90th_percentile": 1390.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1390.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1100.57, "90th_percentile": 3735.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "105", "median_amount": 1376.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5543.5, "90th_percentile": 7424.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "67", "median_amount": 6129.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5611", "type": "APC" } ], "description": "Level 1 Therapeutic Radiation Treatment Preparation", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7159.13, "90th_percentile": 7159.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7159.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1042.53, "90th_percentile": 1042.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1042.53, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 109.75, "90th_percentile": 109.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 109.75, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 148.37, "90th_percentile": 148.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 148.37, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 2456.42, "90th_percentile": 2456.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2456.42, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 3727.19, "90th_percentile": 3727.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3727.19, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1013.59, "90th_percentile": 1013.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1013.59, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5612", "type": "APC" } ], "description": "Level 2 Therapeutic Radiation Treatment Preparation", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 14121.65, "90th_percentile": 42689.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26414.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 463.09, "90th_percentile": 6013.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 4105.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7397.49, "90th_percentile": 7397.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7397.49, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1297.73, "90th_percentile": 46659.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 17435.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2047.97, "90th_percentile": 2935.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2047.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 81.77, "90th_percentile": 3933.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 341.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2639.07, "90th_percentile": 17079.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 13473.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 20204.28, "90th_percentile": 20204.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20204.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2455.41, "90th_percentile": 4682.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4255.57, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6753.53, "90th_percentile": 6753.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6753.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1204.92, "90th_percentile": 35782.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1283.77, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 471.63, "90th_percentile": 471.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 471.63, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3790.65, "90th_percentile": 3790.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3790.65, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 341.85, "90th_percentile": 3864.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1349.74, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1123.66, "90th_percentile": 35079.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22439.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 10476.19, "90th_percentile": 10476.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10476.19, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2533.1, "90th_percentile": 6108.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4251.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4919.64, "90th_percentile": 4919.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4919.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 32191.63, "90th_percentile": 45990.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41063.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 348.78, "90th_percentile": 6141.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 3486.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5257.61, "90th_percentile": 33533.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26386.62, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5613", "type": "APC" } ], "description": "Level 3 Therapeutic Radiation Treatment Preparation", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29245.67, "90th_percentile": 40652.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29245.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1929.35, "90th_percentile": 4741.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 3017.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 25836.01, "90th_percentile": 25836.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25836.01, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16755.48, "90th_percentile": 20589.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 18441.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2791.15, "90th_percentile": 2791.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2791.15, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1723.39, "90th_percentile": 4150.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 2616.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 9192.97, "90th_percentile": 9192.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9192.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2424.22, "90th_percentile": 4342.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2455.41, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 24457.37, "90th_percentile": 31204.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24457.37, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 3368.71, "90th_percentile": 3368.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3368.71, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1494.05, "90th_percentile": 3825.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 2749.61, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8660.6, "90th_percentile": 25093.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 20689.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 3263.4, "90th_percentile": 3693.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3263.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4106.47, "90th_percentile": 4106.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4106.47, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 26203.3, "90th_percentile": 26203.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26203.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2493.54, "90th_percentile": 2493.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2493.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2166.98, "90th_percentile": 4788.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 3834.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15702.5, "90th_percentile": 31336.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21718.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5622", "type": "APC" } ], "description": "Level 2 Radiation Therapy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 8641.97, "90th_percentile": 47925.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 22768.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1351.89, "90th_percentile": 7390.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 3075.85, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 41570.17, "90th_percentile": 44208.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 41570.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4862.16, "90th_percentile": 4862.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4862.16, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3053.38, "90th_percentile": 37833.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 15507.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 781.12, "90th_percentile": 4811.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2343.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 295.66, "90th_percentile": 7505.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 2016.12, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 6288.67, "90th_percentile": 18713.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14106.59, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 676.71, "90th_percentile": 4292.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1283.46, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 339.99, "90th_percentile": 4425.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 2878.96, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 34315.09, "90th_percentile": 34315.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34315.09, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 6889.53, "90th_percentile": 51471.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 32116.93, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 6717.74, "90th_percentile": 6717.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6717.74, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 860.73, "90th_percentile": 5639.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 2761.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13126.75, "90th_percentile": 36583.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 23833.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 15477.66, "90th_percentile": 34063.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17306.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2065.55, "90th_percentile": 4902.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2065.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2625.31, "90th_percentile": 2625.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2625.31, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1224.89, "90th_percentile": 1224.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1224.89, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5501.69, "90th_percentile": 48430.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 31203.09, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1386.06, "90th_percentile": 4444.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1386.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1089.01, "90th_percentile": 7358.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 3377.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4083.88, "90th_percentile": 47182.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 16241.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5623", "type": "APC" } ], "description": "Level 3 Radiation Therapy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 6924.12, "90th_percentile": 58306.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 35039.71, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1326.09, "90th_percentile": 10219.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "62", "median_amount": 7270.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 14530.37, "90th_percentile": 60716.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14530.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3448.2, "90th_percentile": 8479.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5712.04, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3613.94, "90th_percentile": 50607.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "62", "median_amount": 34527.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 556.34, "90th_percentile": 7769.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 4484.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 825.98, "90th_percentile": 10193.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 5246.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1978.29, "90th_percentile": 26369.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10980.99, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 6019.38, "90th_percentile": 7881.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6972.84, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 861.78, "90th_percentile": 10657.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 5895.48, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2047.35, "90th_percentile": 9130.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5813.64, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 9966.07, "90th_percentile": 78086.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 22643.65, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 810.35, "90th_percentile": 9665.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7246.21, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 3527.58, "90th_percentile": 8007.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4087.01, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 825.98, "90th_percentile": 9325.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 4910.41, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3415.75, "90th_percentile": 56439.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 41757.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2129.48, "90th_percentile": 11658.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2129.48, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1744.58, "90th_percentile": 10155.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 3839.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1145.62, "90th_percentile": 7228.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 4954.38, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11675.15, "90th_percentile": 55699.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 41118.93, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 3992.31, "90th_percentile": 7322.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6215.08, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 673.56, "90th_percentile": 10027.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 5853.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5076.75, "90th_percentile": 59392.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "39", "median_amount": 37744.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5624", "type": "APC" } ], "description": "Level 4 Radiation Therapy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 28896.49, "90th_percentile": 51388.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28896.49, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1490.99, "90th_percentile": 7865.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 3886.56, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4359.54, "90th_percentile": 4359.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4359.54, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7886.0, "90th_percentile": 18570.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11829.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2659.23, "90th_percentile": 2659.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2659.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2792.22, "90th_percentile": 7587.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 4169.46, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 18854.38, "90th_percentile": 18854.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18854.38, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 4914.95, "90th_percentile": 4914.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4914.95, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4567.52, "90th_percentile": 4567.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4567.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 51360.16, "90th_percentile": 51360.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 51360.16, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 19358.54, "90th_percentile": 28378.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20034.39, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2190.41, "90th_percentile": 2190.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2190.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 42288.68, "90th_percentile": 42288.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42288.68, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 43099.48, "90th_percentile": 56957.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43099.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5626", "type": "APC" } ], "description": "Level 6 Radiation Therapy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 31013.8, "90th_percentile": 46720.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40146.29, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3134.75, "90th_percentile": 11169.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 7799.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1239.58, "90th_percentile": 1239.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1239.58, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8420.22, "90th_percentile": 40800.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 27184.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5052.26, "90th_percentile": 10295.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 7851.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 15318.79, "90th_percentile": 20229.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15318.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 10739.18, "90th_percentile": 10739.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10739.18, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 28964.28, "90th_percentile": 28964.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28964.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 45615.81, "90th_percentile": 45615.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45615.81, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 5004.51, "90th_percentile": 7896.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5004.51, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4034.6, "90th_percentile": 11117.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 7824.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24290.28, "90th_percentile": 24290.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24290.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 35307.05, "90th_percentile": 35307.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35307.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 7913.19, "90th_percentile": 9749.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8018.98, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5735.91, "90th_percentile": 5735.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5735.91, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 9268.19, "90th_percentile": 9268.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9268.19, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 35252.56, "90th_percentile": 38810.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38586.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4883.61, "90th_percentile": 11555.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 7202.89, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 25157.53, "90th_percentile": 60566.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42797.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5627", "type": "APC" } ], "description": "Level 7 Radiation Therapy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 28379.17, "90th_percentile": 28379.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28379.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8543.48, "90th_percentile": 10324.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8543.48, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 11097.52, "90th_percentile": 46322.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 34751.23, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7262.73, "90th_percentile": 8540.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7262.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 6070.64, "90th_percentile": 6070.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6070.64, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 5415.07, "90th_percentile": 8395.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5631.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 9063.59, "90th_percentile": 9063.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9063.59, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 7138.74, "90th_percentile": 9088.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7138.74, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 67285.87, "90th_percentile": 67285.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67285.87, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 16222.8, "90th_percentile": 16222.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16222.8, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4715.37, "90th_percentile": 4715.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4715.37, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8251.04, "90th_percentile": 8618.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8251.04, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 57258.69, "90th_percentile": 57258.69, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57258.69, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5661", "type": "APC" } ], "description": "Therapeutic Nuclear Medicine", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 382.92, "90th_percentile": 564.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 473.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1380.31, "90th_percentile": 1793.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1380.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 554.97, "90th_percentile": 554.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 554.97, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 995.72, "90th_percentile": 995.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 995.72, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 855.84, "90th_percentile": 855.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 855.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 431.31, "90th_percentile": 431.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 431.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2088.13, "90th_percentile": 2088.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2088.13, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2533.2, "90th_percentile": 2533.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2533.2, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 724.18, "90th_percentile": 724.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 724.18, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2868.05, "90th_percentile": 2868.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2868.05, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5671", "type": "APC" } ], "description": "Level 1 Pathology", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 91.14, "90th_percentile": 362.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1213", "median_amount": 125.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 31.84, "90th_percentile": 459.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 61.88, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27.58, "90th_percentile": 112.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1040", "median_amount": 34.73, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 91.14, "90th_percentile": 362.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "194", "median_amount": 125.58, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 32.17, "90th_percentile": 66.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 36.98, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24.15, "90th_percentile": 96.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "84", "median_amount": 24.15, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47.7, "90th_percentile": 213.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "3564", "median_amount": 72.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 23.11, "90th_percentile": 84.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "116", "median_amount": 28.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27.47, "90th_percentile": 99.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "603", "median_amount": 31.85, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 48.66, "90th_percentile": 284.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 72.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 47.7, "90th_percentile": 217.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "297", "median_amount": 71.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 22.42, "90th_percentile": 97.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "162", "median_amount": 27.53, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31.57, "90th_percentile": 157.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 63.14, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 20.82, "90th_percentile": 86.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "723", "median_amount": 25.26, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25.0, "90th_percentile": 94.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 31.38, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 31.47, "90th_percentile": 97.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "110", "median_amount": 32.57, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 31.47, "90th_percentile": 97.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "526", "median_amount": 32.57, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 31.47, "90th_percentile": 97.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 32.57, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 29.15, "90th_percentile": 170.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "118", "median_amount": 36.28, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2403.8, "90th_percentile": 2403.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2403.8, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 24.15, "90th_percentile": 113.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "112", "median_amount": 29.3, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30.94, "90th_percentile": 123.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "684", "median_amount": 35.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 41.84, "90th_percentile": 162.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1212", "median_amount": 54.15, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 40.44, "90th_percentile": 125.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "130", "median_amount": 52.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 30.94, "90th_percentile": 105.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "153", "median_amount": 35.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 51.81, "90th_percentile": 162.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 83.68, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 60.28, "90th_percentile": 152.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 64.28, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20.82, "90th_percentile": 86.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "277", "median_amount": 25.26, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32.17, "90th_percentile": 99.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "56", "median_amount": 33.11, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 459.55, "90th_percentile": 1640.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "78", "median_amount": 579.74, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 35.61, "90th_percentile": 35.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35.61, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 76.03, "90th_percentile": 256.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "865", "median_amount": 83.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 22.07, "90th_percentile": 98.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "172", "median_amount": 26.78, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30.94, "90th_percentile": 139.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "578", "median_amount": 36.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 78.31, "90th_percentile": 251.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2122", "median_amount": 83.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5672", "type": "APC" } ], "description": "Level 2 Pathology", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 178.83, "90th_percentile": 1146.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "137", "median_amount": 432.09, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 55.47, "90th_percentile": 450.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "193", "median_amount": 158.91, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 394.09, "90th_percentile": 1858.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 640.65, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 206.18, "90th_percentile": 227.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 206.18, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 83.34, "90th_percentile": 563.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 183.34, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 123.97, "90th_percentile": 540.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "416", "median_amount": 241.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 145.9, "90th_percentile": 316.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 179.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 89.33, "90th_percentile": 467.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "138", "median_amount": 176.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 199.1, "90th_percentile": 644.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 300.03, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 126.48, "90th_percentile": 534.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 241.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 126.89, "90th_percentile": 361.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 234.18, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 162.15, "90th_percentile": 1462.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 225.29, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 80.92, "90th_percentile": 302.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "132", "median_amount": 154.98, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 229.28, "90th_percentile": 229.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 229.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 124.28, "90th_percentile": 1070.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 328.46, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 103.17, "90th_percentile": 760.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "45", "median_amount": 269.03, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 100.52, "90th_percentile": 1053.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 240.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 82.83, "90th_percentile": 284.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 132.72, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1103.05, "90th_percentile": 1103.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1103.05, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 135.02, "90th_percentile": 685.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 216.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 77.54, "90th_percentile": 397.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "125", "median_amount": 158.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 101.69, "90th_percentile": 370.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "147", "median_amount": 186.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 98.27, "90th_percentile": 225.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 150.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 99.13, "90th_percentile": 671.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 192.75, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 422.57, "90th_percentile": 548.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 422.57, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 80.92, "90th_percentile": 268.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "55", "median_amount": 153.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 495.79, "90th_percentile": 1027.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 600.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 713.4, "90th_percentile": 3803.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 1971.28, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 285.25, "90th_percentile": 285.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 285.25, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 156.03, "90th_percentile": 1328.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "107", "median_amount": 435.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 85.78, "90th_percentile": 376.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 191.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 87.32, "90th_percentile": 519.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "129", "median_amount": 189.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 246.18, "90th_percentile": 952.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "254", "median_amount": 483.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5673", "type": "APC" } ], "description": "Level 3 Pathology", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 197.97, "90th_percentile": 2624.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "155", "median_amount": 1057.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 251.57, "90th_percentile": 251.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 251.57, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 167.65, "90th_percentile": 872.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "199", "median_amount": 401.63, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 232.6, "90th_percentile": 2085.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 1083.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 642.57, "90th_percentile": 642.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 642.57, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 64.36, "90th_percentile": 838.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 354.83, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 150.99, "90th_percentile": 1260.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "453", "median_amount": 498.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 105.02, "90th_percentile": 478.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 191.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 180.07, "90th_percentile": 638.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "127", "median_amount": 312.27, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 301.42, "90th_percentile": 844.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 593.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 185.0, "90th_percentile": 1832.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 498.13, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 143.65, "90th_percentile": 684.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 310.47, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 630.19, "90th_percentile": 2540.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 630.19, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 67.9, "90th_percentile": 645.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "98", "median_amount": 271.45, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 530.26, "90th_percentile": 939.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 680.85, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 633.14, "90th_percentile": 1379.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 807.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 203.26, "90th_percentile": 1982.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "69", "median_amount": 723.87, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 68.95, "90th_percentile": 989.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 210.37, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 309.55, "90th_percentile": 666.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 417.6, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 575.25, "90th_percentile": 575.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 575.25, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 47.11, "90th_percentile": 671.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 215.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 218.27, "90th_percentile": 744.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "113", "median_amount": 401.63, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 105.05, "90th_percentile": 951.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "128", "median_amount": 427.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 104.56, "90th_percentile": 977.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 488.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 292.63, "90th_percentile": 869.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 401.56, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 105.05, "90th_percentile": 105.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 105.05, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 630.1, "90th_percentile": 960.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 630.5, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 68.02, "90th_percentile": 533.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 299.06, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 341.47, "90th_percentile": 746.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 449.49, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 947.36, "90th_percentile": 2961.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1266.9, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 300.0, "90th_percentile": 2391.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "91", "median_amount": 754.03, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 47.79, "90th_percentile": 461.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 263.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 253.33, "90th_percentile": 759.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "114", "median_amount": 410.47, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 494.1, "90th_percentile": 1871.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "255", "median_amount": 860.41, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5674", "type": "APC" } ], "description": "Level 4 Pathology", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 2089.41, "90th_percentile": 51387.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2089.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 856.45, "90th_percentile": 856.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 856.45, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 306.17, "90th_percentile": 767.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 352.31, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 569.45, "90th_percentile": 569.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 569.45, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 5176.4, "90th_percentile": 5176.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5176.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 2648.95, "90th_percentile": 2648.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2648.95, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 863.9, "90th_percentile": 863.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 863.9, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 697.8, "90th_percentile": 697.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 697.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 261.68, "90th_percentile": 261.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 261.68, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 671.92, "90th_percentile": 671.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 671.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 311.91, "90th_percentile": 311.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 311.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3121.72, "90th_percentile": 3121.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3121.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 250.25, "90th_percentile": 250.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 250.25, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1530.16, "90th_percentile": 22751.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2081.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5691", "type": "APC" } ], "description": "Level 1 Drug Administration", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 6725.07, "90th_percentile": 45662.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 14169.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1206.82, "90th_percentile": 2789.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "85", "median_amount": 2469.79, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 22821.79, "90th_percentile": 104544.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30039.38, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1337.95, "90th_percentile": 2646.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2263.31, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3622.47, "90th_percentile": 14599.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "69", "median_amount": 6364.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1429.6, "90th_percentile": 4521.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1723.69, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1339.6, "90th_percentile": 2649.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 2475.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2158.15, "90th_percentile": 17769.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 6336.77, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1419.56, "90th_percentile": 3967.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2537.13, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 614.0, "90th_percentile": 614.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 614.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1799.59, "90th_percentile": 3412.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 2514.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2496.49, "90th_percentile": 2496.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2496.49, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 22148.4, "90th_percentile": 22148.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 22148.4, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 8947.64, "90th_percentile": 56442.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 13484.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 14732.06, "90th_percentile": 14732.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14732.06, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 1053.1, "90th_percentile": 2487.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1282.71, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1064.87, "90th_percentile": 2923.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2146.08, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1297.24, "90th_percentile": 2695.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "30", "median_amount": 2474.56, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8688.68, "90th_percentile": 29358.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 17377.79, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 700.0, "90th_percentile": 22060.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4187.63, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2287.27, "90th_percentile": 3006.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 2649.81, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 2474.76, "90th_percentile": 2474.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2474.76, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1137.93, "90th_percentile": 3244.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 2536.24, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2149.72, "90th_percentile": 2687.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2218.79, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 33714.01, "90th_percentile": 33714.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33714.01, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7929.42, "90th_percentile": 17855.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 13051.48, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1278.78, "90th_percentile": 2791.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2077.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 716.06, "90th_percentile": 3327.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "50", "median_amount": 2497.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2479.76, "90th_percentile": 21937.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 12126.28, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5692", "type": "APC" } ], "description": "Level 2 Drug Administration", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 245.72, "90th_percentile": 245.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 245.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49.81, "90th_percentile": 49.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 452.44, "90th_percentile": 452.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 452.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1046.28, "90th_percentile": 1046.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1046.28, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 192.23, "90th_percentile": 7024.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 784.16, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 62.09, "90th_percentile": 70.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 62.09, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 111.61, "90th_percentile": 111.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 111.61, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 47.64, "90th_percentile": 118.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 80.72, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 943.91, "90th_percentile": 943.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 943.91, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 1240.75, "90th_percentile": 1240.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1240.75, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 344.18, "90th_percentile": 344.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 344.18, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 333.33, "90th_percentile": 333.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 333.33, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 89.56, "90th_percentile": 22397.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 897.06, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 25.92, "90th_percentile": 248.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25.92, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 72.03, "90th_percentile": 73.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73.02, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 470.71, "90th_percentile": 470.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 470.71, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 434.12, "90th_percentile": 434.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 434.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 40.31, "90th_percentile": 40.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1165.54, "90th_percentile": 1165.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1165.54, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 176.4, "90th_percentile": 67571.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 935.29, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5693", "type": "APC" } ], "description": "Level 3 Drug Administration", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 277.32, "90th_percentile": 13738.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 887.84, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 245.02, "90th_percentile": 2807.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 1125.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 867.87, "90th_percentile": 1272.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 867.87, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 320.97, "90th_percentile": 320.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 320.97, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 158.51, "90th_percentile": 1483.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 506.15, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 120.44, "90th_percentile": 3782.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "71", "median_amount": 567.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 411.29, "90th_percentile": 1010.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 492.2, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 200.77, "90th_percentile": 1151.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 519.04, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 432.52, "90th_percentile": 432.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 432.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 209.57, "90th_percentile": 1088.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 771.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 558.81, "90th_percentile": 4034.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1249.98, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1671.61, "90th_percentile": 1671.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1671.61, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 177.65, "90th_percentile": 1882.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "58", "median_amount": 726.46, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1037.17, "90th_percentile": 3540.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1593.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 381.57, "90th_percentile": 13493.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1156.29, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 404.98, "90th_percentile": 404.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 404.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 325.89, "90th_percentile": 325.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 325.89, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 158.51, "90th_percentile": 1938.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 648.22, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 157.41, "90th_percentile": 6430.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 764.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 447.44, "90th_percentile": 27337.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 988.66, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 459.72, "90th_percentile": 459.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 459.72, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 379.97, "90th_percentile": 7916.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4161.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 427.89, "90th_percentile": 427.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 427.89, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 46.96, "90th_percentile": 46.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 46.96, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 158.51, "90th_percentile": 1344.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 506.15, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 284.42, "90th_percentile": 284.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 284.42, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15938.46, "90th_percentile": 18678.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15938.46, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 343.17, "90th_percentile": 22092.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 1235.49, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 487.76, "90th_percentile": 1099.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 644.74, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 260.07, "90th_percentile": 2738.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 692.66, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 230.71, "90th_percentile": 4820.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 729.38, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5694", "type": "APC" } ], "description": "Level 4 Drug Administration", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 37413.67, "90th_percentile": 37413.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 37413.67, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 637.4, "90th_percentile": 12433.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1822.02, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2251.27, "90th_percentile": 38213.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5279.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 16125.92, "90th_percentile": 16125.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 16125.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 711.65, "90th_percentile": 711.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 711.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 3470.98, "90th_percentile": 12053.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8081.69, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 374.63, "90th_percentile": 1081.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 946.87, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 43168.47, "90th_percentile": 43168.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43168.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2077.03, "90th_percentile": 43299.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2077.03, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 14590.84, "90th_percentile": 106494.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14590.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 14828.7, "90th_percentile": 14828.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14828.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 470.76, "90th_percentile": 470.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 470.76, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 43837.2, "90th_percentile": 47545.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 43974.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 385.06, "90th_percentile": 24341.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 385.06, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5721", "type": "APC" } ], "description": "Level 1 Diagnostic Tests and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 394.27, "90th_percentile": 1095.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 452.89, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 139.11, "90th_percentile": 148.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "64", "median_amount": 146.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 439.55, "90th_percentile": 1095.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 439.55, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 122.08, "90th_percentile": 226.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 135.95, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 362.18, "90th_percentile": 954.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 624.39, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 117.09, "90th_percentile": 216.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 216.86, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 107.8, "90th_percentile": 148.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 146.11, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 135.82, "90th_percentile": 566.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 236.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 195.37, "90th_percentile": 218.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 218.81, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 137.14, "90th_percentile": 253.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 253.98, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 582.29, "90th_percentile": 1490.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1077.28, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 434.22, "90th_percentile": 1274.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 514.44, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 220.42, "90th_percentile": 220.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 220.42, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 203.46, "90th_percentile": 203.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 203.46, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 139.11, "90th_percentile": 146.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "43", "median_amount": 146.11, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 410.21, "90th_percentile": 1209.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 568.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 2226.0, "90th_percentile": 2226.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2226.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 136.31, "90th_percentile": 146.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 136.31, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1109.55, "90th_percentile": 1109.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1109.55, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 122.37, "90th_percentile": 226.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 162.77, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 121.56, "90th_percentile": 121.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 546.94, "90th_percentile": 546.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 546.94, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 418.88, "90th_percentile": 1481.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 471.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 154.36, "90th_percentile": 214.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 206.67, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 98.57, "90th_percentile": 150.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 147.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 398.88, "90th_percentile": 1072.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 790.83, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5722", "type": "APC" } ], "description": "Level 2 Diagnostic Tests and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 392.9, "90th_percentile": 2032.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "96", "median_amount": 1165.23, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 238.65, "90th_percentile": 374.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "199", "median_amount": 290.8, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 769.71, "90th_percentile": 2020.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 1076.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 302.43, "90th_percentile": 302.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 302.43, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 241.66, "90th_percentile": 871.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 264.24, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 580.6, "90th_percentile": 1882.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "255", "median_amount": 998.5, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 231.24, "90th_percentile": 833.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 270.18, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 197.7, "90th_percentile": 294.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "77", "median_amount": 290.8, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 201.1, "90th_percentile": 965.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 514.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 227.79, "90th_percentile": 751.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 255.12, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 513.24, "90th_percentile": 513.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 513.24, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 179.61, "90th_percentile": 976.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "81", "median_amount": 304.28, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 223.3, "90th_percentile": 223.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 223.3, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1385.63, "90th_percentile": 10890.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2311.63, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 484.7, "90th_percentile": 2345.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "48", "median_amount": 1211.88, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 1504.64, "90th_percentile": 1504.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1504.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 146.73, "90th_percentile": 343.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 148.06, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 254.1, "90th_percentile": 871.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 264.24, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 221.5, "90th_percentile": 385.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "127", "median_amount": 290.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 738.18, "90th_percentile": 2095.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "81", "median_amount": 1128.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 460.79, "90th_percentile": 1209.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 644.33, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 267.4, "90th_percentile": 784.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 281.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 160.27, "90th_percentile": 871.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 282.35, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 241.94, "90th_percentile": 302.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 241.94, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3126.29, "90th_percentile": 3126.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3126.29, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 752.19, "90th_percentile": 1646.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 1139.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 151.98, "90th_percentile": 826.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 267.75, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 234.96, "90th_percentile": 392.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "111", "median_amount": 293.71, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 752.19, "90th_percentile": 1974.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "157", "median_amount": 1139.82, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5723", "type": "APC" } ], "description": "Level 3 Diagnostic Tests and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1432.7, "90th_percentile": 15571.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 2148.44, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 477.85, "90th_percentile": 2266.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 496.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 2093.02, "90th_percentile": 8504.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2168.5, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 2482.2, "90th_percentile": 2482.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2482.2, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 264.24, "90th_percentile": 2196.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1301.41, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1427.94, "90th_percentile": 13562.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "108", "median_amount": 2707.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 173.74, "90th_percentile": 1448.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 645.52, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 479.25, "90th_percentile": 2976.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 797.4, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 670.32, "90th_percentile": 9884.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1060.08, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 157.74, "90th_percentile": 1744.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 581.55, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 181.58, "90th_percentile": 2553.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 727.0, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2699.14, "90th_percentile": 2822.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2707.66, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 126.67, "90th_percentile": 31453.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2173.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 437.09, "90th_percentile": 437.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 437.09, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 138.59, "90th_percentile": 4047.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 182.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 396.4, "90th_percentile": 2489.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 497.7, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1604.12, "90th_percentile": 10011.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 2137.85, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 300.0, "90th_percentile": 3573.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 515.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 1983.78, "90th_percentile": 2480.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1983.78, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 180.11, "90th_percentile": 2857.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 674.6, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2757.78, "90th_percentile": 2757.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2757.78, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 857.73, "90th_percentile": 31102.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 2058.87, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 170.8, "90th_percentile": 1627.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 173.52, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 400.37, "90th_percentile": 2951.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 882.34, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1616.72, "90th_percentile": 2113.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "46", "median_amount": 2026.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5724", "type": "APC" } ], "description": "Level 4 Diagnostic Tests and Related Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 3932.8, "90th_percentile": 26823.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6768.07, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1274.16, "90th_percentile": 4143.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 2046.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 26137.77, "90th_percentile": 28875.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26137.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1294.69, "90th_percentile": 2373.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 1612.02, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 3083.82, "90th_percentile": 22666.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "38", "median_amount": 14571.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 1229.58, "90th_percentile": 2066.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 1505.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1096.19, "90th_percentile": 5036.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 2996.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 11106.68, "90th_percentile": 12671.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 11470.51, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1228.7, "90th_percentile": 1323.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1228.7, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1410.66, "90th_percentile": 2191.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 1696.66, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20454.78, "90th_percentile": 20454.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20454.78, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 4722.14, "90th_percentile": 4722.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4722.14, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 2794.41, "90th_percentile": 4367.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2794.41, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1193.35, "90th_percentile": 2779.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1570.66, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 965.08, "90th_percentile": 3814.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 1287.51, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2330.12, "90th_percentile": 23737.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 14608.53, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 10856.76, "90th_percentile": 10856.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 10856.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2541.76, "90th_percentile": 4442.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2541.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1053.61, "90th_percentile": 2099.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 1602.56, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2905.21, "90th_percentile": 2905.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2905.21, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2387.88, "90th_percentile": 26971.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 12812.3, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 1381.06, "90th_percentile": 1698.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1501.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1037.13, "90th_percentile": 4189.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 2581.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1516.02, "90th_percentile": 23483.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 9947.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5731", "type": "APC" } ], "description": "Level 1 Minor Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 33.92, "90th_percentile": 151.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 47.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10.72, "90th_percentile": 23.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 23.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 47.35, "90th_percentile": 151.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 151.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 38.54, "90th_percentile": 38.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 38.54, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18.89, "90th_percentile": 78.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "127", "median_amount": 30.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10.74, "90th_percentile": 23.38, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 23.36, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 30.84, "90th_percentile": 78.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30.84, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 18.13, "90th_percentile": 18.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18.13, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48.6, "90th_percentile": 48.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 48.6, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 8.45, "90th_percentile": 33.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 18.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9.98, "90th_percentile": 45.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27.3, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 9.98, "90th_percentile": 45.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "29", "median_amount": 27.3, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 45.58, "90th_percentile": 45.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 45.58, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 21.88, "90th_percentile": 21.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21.88, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 304.0, "90th_percentile": 304.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 304.0, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 21.02, "90th_percentile": 21.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 21.02, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10.72, "90th_percentile": 23.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 23.36, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 26.06, "90th_percentile": 67.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 32.57, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 31.17, "90th_percentile": 33.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 31.47, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 23.36, "90th_percentile": 23.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 23.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 67.82, "90th_percentile": 67.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 14.74, "90th_percentile": 14.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 14.74, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8.45, "90th_percentile": 25.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8.45, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24.3, "90th_percentile": 24.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 24.3, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 207.46, "90th_percentile": 852.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 249.28, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 28.46, "90th_percentile": 122.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 60.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 19.22, "90th_percentile": 2514.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19.22, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 10.73, "90th_percentile": 24.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 21.92, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 29.32, "90th_percentile": 122.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "94", "median_amount": 60.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5732", "type": "APC" } ], "description": "Level 2 Minor Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 75.58, "90th_percentile": 157.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "90", "median_amount": 151.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 36.95, "90th_percentile": 321.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "114", "median_amount": 130.66, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 75.58, "90th_percentile": 2395.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 151.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 38.54, "90th_percentile": 301.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 301.0, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39.46, "90th_percentile": 80.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "296", "median_amount": 78.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 20.97, "90th_percentile": 357.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 36.87, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 21.95, "90th_percentile": 350.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 144.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 78.92, "90th_percentile": 80.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78.92, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 78.92, "90th_percentile": 2014.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 167.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 20.59, "90th_percentile": 20.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 20.59, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 47.22, "90th_percentile": 47.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47.22, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 18.89, "90th_percentile": 95.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 37.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 23.59, "90th_percentile": 47.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 47.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 23.59, "90th_percentile": 1039.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "51", "median_amount": 47.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 47.18, "90th_percentile": 47.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 47.18, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 38.56, "90th_percentile": 86.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43.55, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25.61, "90th_percentile": 348.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "76", "median_amount": 161.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 55.87, "90th_percentile": 983.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "92", "median_amount": 69.84, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 67.5, "90th_percentile": 67.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 67.5, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 36.25, "90th_percentile": 252.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 107.13, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 35.0, "90th_percentile": 35.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35.0, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 33.22, "90th_percentile": 289.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 124.05, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 163.1, "90th_percentile": 195.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 163.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 239.44, "90th_percentile": 239.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 239.44, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 63.22, "90th_percentile": 707.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "85", "median_amount": 126.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 20.02, "90th_percentile": 184.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 35.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 37.02, "90th_percentile": 342.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "118", "median_amount": 148.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 63.22, "90th_percentile": 126.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "155", "median_amount": 122.76, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5733", "type": "APC" } ], "description": "Level 3 Minor Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 85.94, "90th_percentile": 497.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "125", "median_amount": 156.18, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50.97, "90th_percentile": 221.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "278", "median_amount": 55.69, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 100.83, "90th_percentile": 282.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 169.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 33.18, "90th_percentile": 57.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 33.18, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 29.44, "90th_percentile": 86.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 29.44, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 83.08, "90th_percentile": 267.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "330", "median_amount": 132.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 28.17, "90th_percentile": 164.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 82.56, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44.37, "90th_percentile": 392.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "133", "median_amount": 56.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 46.82, "90th_percentile": 328.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 75.05, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 28.43, "90th_percentile": 222.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 71.52, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 55.08, "90th_percentile": 198.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 77.52, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 32.99, "90th_percentile": 131.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "102", "median_amount": 76.23, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 433.09, "90th_percentile": 433.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 433.09, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 133.57, "90th_percentile": 1544.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 281.53, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 79.68, "90th_percentile": 813.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "58", "median_amount": 155.5, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 126.38, "90th_percentile": 296.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 292.75, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 28.87, "90th_percentile": 56.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 56.6, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 29.44, "90th_percentile": 430.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 86.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 32.35, "90th_percentile": 334.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "232", "median_amount": 56.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 94.1, "90th_percentile": 300.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "96", "median_amount": 156.74, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 53.24, "90th_percentile": 764.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 54.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 46.68, "90th_percentile": 392.49, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "66", "median_amount": 56.07, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 28.23, "90th_percentile": 28.23, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 28.23, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 29.44, "90th_percentile": 516.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "40", "median_amount": 68.03, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 57.68, "90th_percentile": 226.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 57.68, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 164.82, "90th_percentile": 386.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 288.64, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 86.47, "90th_percentile": 314.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "82", "median_amount": 184.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 27.92, "90th_percentile": 98.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 64.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44.02, "90th_percentile": 246.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "171", "median_amount": 56.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 96.08, "90th_percentile": 412.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "239", "median_amount": 184.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5734", "type": "APC" } ], "description": "Level 4 Minor Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 42.71, "90th_percentile": 467.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "275", "median_amount": 222.78, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 39.31, "90th_percentile": 120.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "290", "median_amount": 120.37, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 63.97, "90th_percentile": 386.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 245.81, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 104.56, "90th_percentile": 125.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 118.32, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 13.7, "90th_percentile": 156.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "90", "median_amount": 36.88, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 23.78, "90th_percentile": 497.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "707", "median_amount": 190.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 13.12, "90th_percentile": 135.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "114", "median_amount": 35.73, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 82.61, "90th_percentile": 120.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "178", "median_amount": 120.37, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 23.79, "90th_percentile": 264.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 147.02, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 21.59, "90th_percentile": 360.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "90", "median_amount": 106.17, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 11.81, "90th_percentile": 115.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "99", "median_amount": 38.54, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 24.84, "90th_percentile": 258.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 121.32, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 11.81, "90th_percentile": 170.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "521", "median_amount": 91.21, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 97.26, "90th_percentile": 121.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 114.9, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 48.95, "90th_percentile": 795.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 260.46, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 24.69, "90th_percentile": 656.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "108", "median_amount": 284.98, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 53.47, "90th_percentile": 122.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 116.09, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 163.8, "90th_percentile": 163.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 163.8, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 13.7, "90th_percentile": 176.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "116", "median_amount": 37.33, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 48.15, "90th_percentile": 121.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "199", "median_amount": 120.37, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18.34, "90th_percentile": 545.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "166", "median_amount": 229.4, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 96.66, "90th_percentile": 464.33, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "25", "median_amount": 185.67, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 48.35, "90th_percentile": 120.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "32", "median_amount": 113.76, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 11.81, "90th_percentile": 146.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "214", "median_amount": 97.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 63.42, "90th_percentile": 125.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 125.19, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 171.87, "90th_percentile": 489.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "33", "median_amount": 206.64, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 126.39, "90th_percentile": 126.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 126.39, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 37.88, "90th_percentile": 633.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "189", "median_amount": 189.56, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 19.33, "90th_percentile": 157.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "151", "median_amount": 95.79, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 56.02, "90th_percentile": 124.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "210", "median_amount": 121.58, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 45.07, "90th_percentile": 555.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "445", "median_amount": 178.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5735", "type": "APC" } ], "description": "Level 5 Minor Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 964.36, "90th_percentile": 964.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 964.36, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5742", "type": "APC" } ], "description": "Level 2 Electronic Analysis of Devices", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 258.99, "90th_percentile": 258.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 258.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 85.72, "90th_percentile": 2116.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 86.21, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 78.62, "90th_percentile": 163.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78.62, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15530.81, "90th_percentile": 15530.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 15530.81, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 181.28, "90th_percentile": 181.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 181.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17276.79, "90th_percentile": 17276.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17276.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 253.37, "90th_percentile": 2023.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 332.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 42.57, "90th_percentile": 42.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 42.57, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 361.8, "90th_percentile": 361.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 361.8, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 131.03, "90th_percentile": 131.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 131.03, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 210.43, "90th_percentile": 210.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 210.43, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 75.91, "90th_percentile": 75.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 75.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 94.1, "90th_percentile": 94.1, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 94.1, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 107.84, "90th_percentile": 107.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 107.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69.26, "90th_percentile": 14629.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 885.72, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5771", "type": "APC" } ], "description": "Cardiac Rehabilitation", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 599.69, "90th_percentile": 3536.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "180", "median_amount": 1945.26, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 141.09, "90th_percentile": 1410.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "499", "median_amount": 706.08, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 324.21, "90th_percentile": 3046.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 1586.41, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 396.88, "90th_percentile": 396.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 396.88, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 86.62, "90th_percentile": 1039.44, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 692.96, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 366.34, "90th_percentile": 2696.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "416", "median_amount": 1616.49, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 102.37, "90th_percentile": 940.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 497.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 118.28, "90th_percentile": 1090.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "229", "median_amount": 587.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 300.51, "90th_percentile": 1590.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "78", "median_amount": 923.58, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 83.63, "90th_percentile": 752.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 501.78, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 686.3, "90th_percentile": 727.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 686.3, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 97.07, "90th_percentile": 1026.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 485.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 539.32, "90th_percentile": 3702.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "26", "median_amount": 1852.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 328.76, "90th_percentile": 3284.63, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 2068.2, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 1279.6, "90th_percentile": 2559.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1934.48, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 155.88, "90th_percentile": 1199.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 594.86, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 433.1, "90th_percentile": 606.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 433.1, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 117.78, "90th_percentile": 1295.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "304", "median_amount": 613.99, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 482.35, "90th_percentile": 2679.3, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "143", "median_amount": 1725.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 553.3, "90th_percentile": 1827.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 1106.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 118.38, "90th_percentile": 1302.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 812.03, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5172.91, "90th_percentile": 5172.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5172.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 173.24, "90th_percentile": 1019.46, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "49", "median_amount": 519.72, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 97.82, "90th_percentile": 1076.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 293.46, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 619.8, "90th_percentile": 867.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 619.8, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 409.58, "90th_percentile": 2789.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "111", "median_amount": 1685.55, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 164.28, "90th_percentile": 947.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 574.98, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 118.76, "90th_percentile": 1425.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "289", "median_amount": 665.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 528.14, "90th_percentile": 3456.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "227", "median_amount": 1843.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5781", "type": "APC" } ], "description": "Resuscitation and Cardioversion", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 4527.77, "90th_percentile": 8090.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 5660.0, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 580.09, "90th_percentile": 852.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "207", "median_amount": 611.59, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 5282.28, "90th_percentile": 20652.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5282.28, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 635.53, "90th_percentile": 913.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 635.53, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 497.9, "90th_percentile": 497.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 497.9, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4174.73, "90th_percentile": 5898.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "83", "median_amount": 4941.0, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 476.43, "90th_percentile": 1076.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 476.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 307.29, "90th_percentile": 956.99, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "61", "median_amount": 617.29, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 2429.09, "90th_percentile": 2978.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "13", "median_amount": 2519.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 480.73, "90th_percentile": 956.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 480.73, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 557.99, "90th_percentile": 1133.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 557.99, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 8104.26, "90th_percentile": 9030.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8717.1, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 5316.84, "90th_percentile": 7087.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6039.41, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 350.96, "90th_percentile": 350.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 350.96, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 528.55, "90th_percentile": 623.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 616.67, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 497.9, "90th_percentile": 497.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 497.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 503.29, "90th_percentile": 951.09, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "119", "median_amount": 613.29, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5114.24, "90th_percentile": 6581.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 5787.7, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 248.54, "90th_percentile": 3626.93, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3196.08, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 579.83, "90th_percentile": 1060.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 611.3, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 497.9, "90th_percentile": 991.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 497.9, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 508.42, "90th_percentile": 508.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 508.42, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 9132.25, "90th_percentile": 9132.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9132.25, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4264.1, "90th_percentile": 10703.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 5343.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 472.14, "90th_percentile": 472.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 472.14, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 383.21, "90th_percentile": 959.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "81", "median_amount": 619.21, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 5090.43, "90th_percentile": 6644.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "44", "median_amount": 5513.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5791", "type": "APC" } ], "description": "Pulmonary Treatment", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 44259.16, "90th_percentile": 44259.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44259.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1291.81, "90th_percentile": 1291.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1291.81, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30539.75, "90th_percentile": 31685.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30539.75, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 189.91, "90th_percentile": 189.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 189.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 452.36, "90th_percentile": 452.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 452.36, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 708.31, "90th_percentile": 708.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 708.31, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5801", "type": "APC" } ], "description": "Ventilation Initiation and Management", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 4412.15, "90th_percentile": 4412.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4412.15, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5822", "type": "APC" } ], "description": "Level 2 Health and Behavior Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1076.0, "90th_percentile": 8288.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22", "median_amount": 2689.99, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 86.88, "90th_percentile": 952.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 238.17, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 455.03, "90th_percentile": 5621.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 1873.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 84.0, "90th_percentile": 2441.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 455.96, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1571.59, "90th_percentile": 1571.59, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1571.59, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 800.04, "90th_percentile": 800.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 800.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 490.73, "90th_percentile": 490.73, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 490.73, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1327.4, "90th_percentile": 1327.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1327.4, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1991.1, "90th_percentile": 7098.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 3371.27, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 432.54, "90th_percentile": 432.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 432.54, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1271.09, "90th_percentile": 6347.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 3266.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 594.98, "90th_percentile": 3986.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2677.41, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1050.26, "90th_percentile": 1050.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1050.26, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 940.21, "90th_percentile": 5815.2, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 2820.16, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 178.04, "90th_percentile": 1222.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 445.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1005.6, "90th_percentile": 6536.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 4022.4, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5823", "type": "APC" } ], "description": "Level 3 Health and Behavior Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 1296.96, "90th_percentile": 23161.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17690.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 186.83, "90th_percentile": 186.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 186.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 150.54, "90th_percentile": 150.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 150.54, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 6419.98, "90th_percentile": 6419.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 6419.98, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 539.15, "90th_percentile": 19624.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 8094.55, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 2412.66, "90th_percentile": 2796.53, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2412.66, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 9048.43, "90th_percentile": 9048.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 9048.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 2513.36, "90th_percentile": 2513.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2513.36, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1299.74, "90th_percentile": 1299.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1299.74, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 1352.26, "90th_percentile": 2641.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 1903.2, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 26856.7, "90th_percentile": 26856.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 26856.7, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1722.6, "90th_percentile": 25439.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7937.3, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 1632.27, "90th_percentile": 2849.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1915.38, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 152.04, "90th_percentile": 152.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 152.04, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 6710.31, "90th_percentile": 23234.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18419.49, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 8008.91, "90th_percentile": 8008.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 8008.91, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1025.16, "90th_percentile": 1862.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1481.58, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 300.77, "90th_percentile": 20476.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 5544.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 989.64, "90th_percentile": 1210.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 989.64, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4704.0, "90th_percentile": 21614.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12", "median_amount": 16401.27, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "5871", "type": "APC" } ], "description": "Dental Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2880.76, "90th_percentile": 2880.76, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2880.76, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 0.01, "90th_percentile": 0.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 0.01, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 4491.74, "90th_percentile": 4491.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4491.74, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 4079.52, "90th_percentile": 4079.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4079.52, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 3683.96, "90th_percentile": 3683.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3683.96, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 18928.85, "90th_percentile": 18928.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18928.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "9132", "type": "APC" } ], "description": "Prothrombin complex kcentra", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 7427.45, "90th_percentile": 7427.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 7427.45, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "9518", "type": "APC" } ], "description": "Washed red blood cells unit", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 740.75, "90th_percentile": 740.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 740.75, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "9522", "type": "APC" } ], "description": "RBC leukoreduced irradiated", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2442.04, "90th_percentile": 2442.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2442.04, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "9530", "type": "APC" } ], "description": "Plate pheres leukoredu irrad", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1628.17, "90th_percentile": 1628.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1628.17, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "9536", "type": "APC" } ], "description": "Platelets pheresis path redu", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 2349.11, "90th_percentile": 2349.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2349.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 489.71, "90th_percentile": 489.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 489.71, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 877.9, "90th_percentile": 877.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 877.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N800", "type": "APC" } ], "description": "Clinical Diagnostic Lab Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 29.88, "90th_percentile": 171.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "7929", "median_amount": 87.97, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 11.29, "90th_percentile": 198.05, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 24.15, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 8.29, "90th_percentile": 94.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "7209", "median_amount": 24.53, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 29.88, "90th_percentile": 171.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1320", "median_amount": 91.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 16.92, "90th_percentile": 105.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "157", "median_amount": 46.59, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 17.87, "90th_percentile": 114.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1405", "median_amount": 58.25, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18.54, "90th_percentile": 104.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "22151", "median_amount": 52.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 20.59, "90th_percentile": 122.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1544", "median_amount": 58.44, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16.38, "90th_percentile": 100.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "4108", "median_amount": 32.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24.56, "90th_percentile": 131.55, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "101", "median_amount": 57.57, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 18.12, "90th_percentile": 100.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2059", "median_amount": 48.28, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 19.0, "90th_percentile": 112.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1906", "median_amount": 54.91, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18.28, "90th_percentile": 96.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "249", "median_amount": 67.16, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 18.11, "90th_percentile": 109.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "8360", "median_amount": 60.01, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4.24, "90th_percentile": 98.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "123", "median_amount": 34.78, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 24.63, "90th_percentile": 142.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "811", "median_amount": 64.62, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 19.34, "90th_percentile": 142.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "3311", "median_amount": 56.06, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 24.63, "90th_percentile": 136.56, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "171", "median_amount": 84.86, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 16.86, "90th_percentile": 96.81, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "512", "median_amount": 27.48, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 42.62, "90th_percentile": 209.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 96.81, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 22.28, "90th_percentile": 114.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1541", "median_amount": 61.06, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15.25, "90th_percentile": 94.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "4673", "median_amount": 29.32, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 20.95, "90th_percentile": 115.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "7852", "median_amount": 53.26, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 15.36, "90th_percentile": 90.54, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "965", "median_amount": 44.73, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 16.26, "90th_percentile": 94.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1336", "median_amount": 27.88, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 15.65, "90th_percentile": 119.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "50", "median_amount": 29.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 17.96, "90th_percentile": 127.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 41.6, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 19.02, "90th_percentile": 98.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "3462", "median_amount": 52.64, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15.86, "90th_percentile": 107.28, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "386", "median_amount": 47.53, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 63.96, "90th_percentile": 283.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "582", "median_amount": 146.78, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 8.0, "90th_percentile": 215.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17.21, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 39.0, "90th_percentile": 234.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "6082", "median_amount": 100.26, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 17.87, "90th_percentile": 88.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1887", "median_amount": 55.8, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 16.53, "90th_percentile": 98.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "4699", "median_amount": 33.7, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 40.62, "90th_percentile": 245.61, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "12740", "median_amount": 127.63, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N801", "type": "APC" } ], "description": "Therapy Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 57.78, "90th_percentile": 1461.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1093", "median_amount": 125.19, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 76.25, "90th_percentile": 522.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 76.25, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 58.94, "90th_percentile": 689.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1267", "median_amount": 177.27, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 39.31, "90th_percentile": 1596.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "131", "median_amount": 166.92, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 51.98, "90th_percentile": 364.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "18", "median_amount": 143.42, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 100.25, "90th_percentile": 1177.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "126", "median_amount": 104.25, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50.31, "90th_percentile": 1283.22, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2041", "median_amount": 138.24, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 95.93, "90th_percentile": 529.37, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "203", "median_amount": 99.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50.53, "90th_percentile": 664.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "520", "median_amount": 147.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 145.34, "90th_percentile": 1389.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 145.34, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 28.35, "90th_percentile": 1074.64, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "183", "median_amount": 86.32, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 86.42, "90th_percentile": 885.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "224", "median_amount": 100.65, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 70.2, "90th_percentile": 4557.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "20", "median_amount": 514.6, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 90.0, "90th_percentile": 554.82, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1008", "median_amount": 116.83, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 25.35, "90th_percentile": 716.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 94.82, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 88.61, "90th_percentile": 1175.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 215.54, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 61.65, "90th_percentile": 1537.15, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "334", "median_amount": 169.26, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 30.83, "90th_percentile": 223.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 129.68, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 74.7, "90th_percentile": 482.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "64", "median_amount": 181.07, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 104.25, "90th_percentile": 1118.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "164", "median_amount": 159.84, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 60.8, "90th_percentile": 629.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "645", "median_amount": 166.18, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 56.88, "90th_percentile": 1338.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "921", "median_amount": 159.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 31.59, "90th_percentile": 984.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "92", "median_amount": 179.28, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 50.06, "90th_percentile": 533.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "150", "median_amount": 147.62, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 159.9, "90th_percentile": 159.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 159.9, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 100.25, "90th_percentile": 639.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "396", "median_amount": 104.25, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 76.45, "90th_percentile": 623.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "79", "median_amount": 140.27, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 58.5, "90th_percentile": 474.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 58.5, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 56.52, "90th_percentile": 1282.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "554", "median_amount": 144.9, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 90.0, "90th_percentile": 669.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "235", "median_amount": 98.86, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 62.88, "90th_percentile": 545.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "555", "median_amount": 150.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 56.52, "90th_percentile": 1294.31, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1691", "median_amount": 122.46, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N804", "type": "APC" } ], "description": "Mammography Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 149.64, "90th_percentile": 206.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2478", "median_amount": 200.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "10th_percentile": 83.95, "90th_percentile": 83.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83.95, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 100.83, "90th_percentile": 103.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2849", "median_amount": 100.83, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 200.94, "90th_percentile": 206.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "339", "median_amount": 200.94, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "10th_percentile": 104.86, "90th_percentile": 104.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 104.86, "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 93.65, "90th_percentile": 97.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "96", "median_amount": 97.39, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 169.97, "90th_percentile": 180.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "5933", "median_amount": 174.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 89.61, "90th_percentile": 93.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "144", "median_amount": 93.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 100.83, "90th_percentile": 103.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1364", "median_amount": 100.83, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 169.97, "90th_percentile": 203.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 174.98, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 98.6, "90th_percentile": 103.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "863", "median_amount": 98.6, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 80.73, "90th_percentile": 94.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "183", "median_amount": 83.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 112.68, "90th_percentile": 112.68, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "42", "median_amount": 112.68, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 104.95, "90th_percentile": 109.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "918", "median_amount": 109.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 101.83, "90th_percentile": 101.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "41", "median_amount": 101.83, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 259.47, "90th_percentile": 273.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "210", "median_amount": 266.67, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 203.77, "90th_percentile": 265.43, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "915", "median_amount": 208.15, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 208.15, "90th_percentile": 273.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 259.47, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 102.88, "90th_percentile": 105.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "194", "median_amount": 102.88, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 203.45, "90th_percentile": 203.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 203.45, "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 93.65, "90th_percentile": 97.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "139", "median_amount": 97.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 100.83, "90th_percentile": 103.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1870", "median_amount": 100.83, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 112.52, "90th_percentile": 115.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "2563", "median_amount": 112.52, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 107.9, "90th_percentile": 109.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "362", "median_amount": 108.36, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 100.82, "90th_percentile": 103.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "379", "median_amount": 100.82, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 112.52, "90th_percentile": 143.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 142.81, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "10th_percentile": 103.75, "90th_percentile": 103.75, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 103.75, "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 93.65, "90th_percentile": 97.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "321", "median_amount": 97.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 104.86, "90th_percentile": 107.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "108", "median_amount": 104.86, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 203.45, "90th_percentile": 256.66, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "53", "median_amount": 256.66, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "10th_percentile": 105.86, "90th_percentile": 105.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 105.86, "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 196.56, "90th_percentile": 201.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1473", "median_amount": 196.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 88.8, "90th_percentile": 92.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "204", "median_amount": 92.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 101.83, "90th_percentile": 104.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1309", "median_amount": 101.85, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 196.57, "90th_percentile": 201.57, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "4596", "median_amount": 201.57, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N805", "type": "APC" } ], "description": "Durable Medical Equipment", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 944.06, "90th_percentile": 944.06, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 944.06, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 133.78, "90th_percentile": 133.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 133.78, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 2221.95, "90th_percentile": 2221.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2221.95, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N806", "type": "APC" } ], "description": "Pharmacy Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 25.65, "90th_percentile": 25.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 25.65, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N809", "type": "APC" } ], "description": "Other Medicine", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 506.78, "90th_percentile": 1521.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 585.51, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 77.82, "90th_percentile": 591.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "37", "median_amount": 215.16, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 518.1, "90th_percentile": 2091.01, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 518.1, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 354.41, "90th_percentile": 1247.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "24", "median_amount": 614.35, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 92.66, "90th_percentile": 358.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "11", "median_amount": 169.62, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 254.21, "90th_percentile": 961.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 254.21, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 1379.07, "90th_percentile": 1379.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1379.07, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 597.1, "90th_percentile": 1253.91, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 847.31, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 538.35, "90th_percentile": 538.35, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 538.35, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 1111.26, "90th_percentile": 1111.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1111.26, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 101.86, "90th_percentile": 127.42, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 101.86, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 265.93, "90th_percentile": 756.07, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 265.93, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 81.68, "90th_percentile": 323.62, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "21", "median_amount": 175.76, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 795.81, "90th_percentile": 2168.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1197.95, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 792.86, "90th_percentile": 792.86, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 792.86, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 336.33, "90th_percentile": 503.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 464.22, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 329.83, "90th_percentile": 329.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 329.83, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 506.79, "90th_percentile": 1036.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 563.32, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 505.24, "90th_percentile": 505.24, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 505.24, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 182.14, "90th_percentile": 579.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "16", "median_amount": 342.11, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 420.95, "90th_percentile": 2383.17, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1129.13, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N900", "type": "APC" } ], "description": "Non-covered Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 185.18, "90th_percentile": 617.21, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "67", "median_amount": 539.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 89.6, "90th_percentile": 110.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "106", "median_amount": 89.6, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 525.79, "90th_percentile": 599.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 539.72, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 97.39, "90th_percentile": 97.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 97.39, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 31.53, "90th_percentile": 508.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "264", "median_amount": 457.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 93.19, "90th_percentile": 93.19, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 93.19, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 71.68, "90th_percentile": 112.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "36", "median_amount": 91.43, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 40.79, "90th_percentile": 40.79, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 40.79, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 257.99, "90th_percentile": 286.34, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 271.9, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 83.95, "90th_percentile": 94.03, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 83.95, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 294.84, "90th_percentile": 294.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 294.84, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 109.13, "90th_percentile": 109.13, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "27", "median_amount": 109.13, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 561.02, "90th_percentile": 810.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 714.99, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 253.24, "90th_percentile": 678.95, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "35", "median_amount": 561.02, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 544.64, "90th_percentile": 561.02, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 544.64, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "10th_percentile": 16.43, "90th_percentile": 97.08, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 73.88, "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 97.39, "90th_percentile": 97.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 97.39, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 76.11, "90th_percentile": 110.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "77", "median_amount": 89.6, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 503.69, "90th_percentile": 590.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "74", "median_amount": 532.35, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 63.27, "90th_percentile": 322.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 285.02, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "10th_percentile": 89.6, "90th_percentile": 110.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 90.6, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 97.39, "90th_percentile": 97.39, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 97.39, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 77.42, "90th_percentile": 101.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 94.73, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 671.58, "90th_percentile": 671.58, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 671.58, "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 280.67, "90th_percentile": 585.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "34", "median_amount": 527.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 92.35, "90th_percentile": 114.18, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 92.35, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 90.5, "90th_percentile": 118.36, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "52", "median_amount": 96.1, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 450.61, "90th_percentile": 585.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "143", "median_amount": 527.44, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N902", "type": "APC" } ], "description": "Packaged Services", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2.87, "90th_percentile": 2.87, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2.87, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 30.95, "90th_percentile": 2175.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 30.95, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 131.89, "90th_percentile": 131.89, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 131.89, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 180.97, "90th_percentile": 180.97, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 180.97, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "10th_percentile": 2.8, "90th_percentile": 2.8, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2.8, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 43.65, "90th_percentile": 43.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 43.65, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 4.52, "90th_percentile": 4.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4.52, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 398.12, "90th_percentile": 398.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 398.12, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 2.65, "90th_percentile": 2.65, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2.65, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N905", "type": "APC" } ], "description": "Not Recognized by OPPS", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 420.09, "90th_percentile": 2575.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "72", "median_amount": 2191.35, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 283.82, "90th_percentile": 346.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "28", "median_amount": 334.86, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 800.0, "90th_percentile": 2653.45, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2567.33, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 483.52, "90th_percentile": 483.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 483.52, "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 394.21, "90th_percentile": 2568.26, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "207", "median_amount": 2168.91, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "10th_percentile": 358.14, "90th_percentile": 358.14, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 358.14, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 108.16, "90th_percentile": 346.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 283.82, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 176.62, "90th_percentile": 1060.29, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "23", "median_amount": 971.76, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "10th_percentile": 466.85, "90th_percentile": 466.85, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 466.85, "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1224.04, "90th_percentile": 1224.04, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1224.04, "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "10th_percentile": 541.88, "90th_percentile": 541.88, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "15", "median_amount": 541.88, "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2374.09, "90th_percentile": 2867.83, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2555.27, "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 364.42, "90th_percentile": 2555.27, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "31", "median_amount": 2005.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "10th_percentile": 1604.0, "90th_percentile": 2367.94, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1604.0, "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 15.0, "90th_percentile": 348.5, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "14", "median_amount": 71.12, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 389.42, "90th_percentile": 2508.78, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "66", "median_amount": 2237.25, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "10th_percentile": 241.82, "90th_percentile": 1191.47, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "17", "median_amount": 1045.32, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 389.21, "90th_percentile": 483.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 464.97, "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 734.13, "90th_percentile": 2792.72, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "54", "median_amount": 2370.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "10th_percentile": 458.51, "90th_percentile": 458.51, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 458.51, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 178.93, "90th_percentile": 339.84, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "19", "median_amount": 336.84, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 451.02, "90th_percentile": 2787.92, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "128", "median_amount": 2370.61, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "N908", "type": "APC" } ], "description": "Partial Hospitalization", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 2862.32, "90th_percentile": 2862.32, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2862.32, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 62.5] [Observation (%BC): 62.5] [Emergency Department (%BC): 71.6] [CT OP Scan (%BC): 71.6] [MRI OP (%BC): 71.6] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.5] [Physical Therapy (%BC): 62.5] [Respiratory Services/Therapy (%BC): 62.5] [Speech Therapy (%BC): 62.5] [Other Outpatient Implant (%BC): 62.4] [All Other OP (%BC): 62.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE] [All Other OP (%BC): 29.6]" }, { "10th_percentile": 1107.12, "90th_percentile": 1107.12, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1107.12, "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 76.4] [Observation (%BC): 76.4] [Emergency Department (%BC): 76.4] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 76.4] [Physical Therapy (%BC): 76.4] [Respiratory Services/Therapy (%BC): 76.4] [Speech Therapy (%BC): 76.4] [All Other OP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 1935.36, "90th_percentile": 6359.16, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 3682.74, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 16564] [Observation (%BC): 55.9 Maximum Reimbursement 2629] [Emergency Department (%BC): 74.1] [Urgent Care (%BC): 74.1] [CT OP Scan (%BC): 74.1] [MRI OP (%BC): 74.1] [MRI OP ($): 1213] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 55.9] [Physical Therapy (%BC): 55.9] [Respiratory Services/Therapy (%BC): 55.9] [Speech Therapy (%BC): 55.9] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 55.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 100] [Observation (%BC): 100 Maximum Reimbursement 2629] [Emergency Department (%BC): 100] [CT OP Scan (%BC): 100] [MRI OP ($): 1179] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 100] [Physical Therapy (%BC): 100] [Respiratory Services/Therapy (%BC): 100] [Speech Therapy (%BC): 100] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 100]" }, { "10th_percentile": 1194.48, "90th_percentile": 1194.48, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1194.48, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [All OP services (%BC): 33.2] [OP Surgery (%BC): 33.2] [Observation (%BC): 33.2] [Emergency Department (%BC): 33.2] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 33.2] [Physical Therapy (%BC): 33.2] [Respiratory Services/Therapy (%BC): 33.2] [Speech Therapy (%BC): 33.2] [All Other OP (%BC): 33.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All OP services (%BC): 36] [OP Surgery (%BC): 36] [Observation (%BC): 36] [Emergency Department (%BC): 36] [Occupational Therapy (%BC): 36] [Physical Therapy (%BC): 36] [Respiratory Services/Therapy (%BC): 36] [Speech Therapy (%BC): 36] [Other Pharmacy ($): FEE SCHEDULE] [All Other OP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[OP Surgery (%BC): 82.9] [Observation (%BC): 82.9] [Emergency Department (%BC): 82.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 82.9] [Physical Therapy (%BC): 82.9] [Respiratory Services/Therapy (%BC): 82.9] [Speech Therapy (%BC): 82.9] [All Other OP (%BC): 82.9]" }, { "10th_percentile": 4889.96, "90th_percentile": 7403.98, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4889.96, "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[OP Surgery (%BC): 65.1] [Observation (%BC): 65.1] [Emergency Department (%BC): 65.1] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 65.1] [Physical Therapy (%BC): 65.1] [Respiratory Services/Therapy (%BC): 65.1] [Speech Therapy (%BC): 65.1] [All Other OP (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[OP Surgery (%BC): 80.9] [Observation (%BC): 80.9] [Emergency Department (%BC): 80.9] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 80.9] [Physical Therapy (%BC): 80.9] [Respiratory Services/Therapy (%BC): 80.9] [Speech Therapy (%BC): 80.9] [All Other OP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 94] [OP Surgery (%BC): 94] [Observation (%BC): 94] [Emergency Department (%BC): 94] [Occupational Therapy (%BC): 94] [Physical Therapy (%BC): 94] [Respiratory Services/Therapy (%BC): 94] [Speech Therapy (%BC): 94] [All Other OP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 1274.11, "90th_percentile": 1274.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 1274.11, "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[OP Surgery (%BC): 61.7] [Observation (%BC): 63.2] [Emergency Department (%BC): 73.2] [Urgent Care (%BC): 73.2] [Clinic Visit ($): FEE SCHEDULE] [CT OP Scan (%BC): 73.2] [MRI OP (%BC): 73.2] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 63.2] [Physical Therapy (%BC): 63.2] [Respiratory Services/Therapy (%BC): 63.2] [Speech Therapy (%BC): 63.2] [Other Outpatient Implant (%BC): 63.8] [All Other OP (%BC): 63.2]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[OP Surgery (%BC): 35.4] [Observation (%BC): 35.4] [Emergency Department (%BC): 35.4] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 35.4] [Physical Therapy (%BC): 35.4] [Respiratory Services/Therapy (%BC): 35.4] [Speech Therapy (%BC): 35.4] [All Other OP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[OP Surgery (%BC): 87.7] [Observation (%BC): 87.7] [Emergency Department (%BC): 87.7] [Clinic Visit ($): FEE SCHEDULE] [Mammography-Screening ($): 85.98] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 87.7] [Physical Therapy (%BC): 87.7] [Respiratory Services/Therapy (%BC): 87.7] [Speech Therapy (%BC): 87.7] [All Other OP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All OP services (%BC): 95] [OP Surgery (%BC): 95] [Observation (%BC): 95] [Emergency Department (%BC): 95] [Occupational Therapy (%BC): 95] [Physical Therapy (%BC): 95] [Respiratory Services/Therapy (%BC): 95] [Speech Therapy (%BC): 95] [All Other OP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[APC ($): FEE SCHEDULE]" }, { "10th_percentile": 453.6, "90th_percentile": 453.6, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 453.6, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 63.9 Maximum Reimbursement 20259] [OP Surg. Ungroupable (%BC): 63.9] [Observation (%BC): 62.8] [ED Level 1--99281 ($): 604] [ED Level 2--99282 ($): 1221] [ED Level 3--99283 ($): 2332] [Critical Care (%BC): 79.3] [Urgent Care ($): 604] [Sleep Studies ($): 3876] [CT OP Scan (%BC): 79.3] [MRI OP (%BC): 79.3] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 62.8] [Physical Therapy (%BC): 62.8] [Respiratory Services/Therapy (%BC): 62.8] [Speech Therapy (%BC): 62.8] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 61.0] [All Other OP (%BC): 62.8]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[Ambulance--Air ($): 2300] [Ambulance--Land ($): 350] [APC ($): FEE SCHEDULE]" }, { "10th_percentile": 2856.0, "90th_percentile": 2856.0, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 2856.0, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [OP Surgery (%BC): 66.2 Maximum Reimbursement 21017] [OP Surg. Ungroupable (%BC): 66.2] [Observation (%BC): 64.9] [ED Level 1--99281 ($): 629] [ED Level 2--99282 ($): 1263] [ED Level 3--99283 ($): 2421] [Critical Care (%BC): 82.8] [Urgent Care ($): 629] [Sleep Studies ($): 4108] [CT OP Scan (%BC): 82.8] [MRI OP (%BC): 82.8] [Laboratory Fee Schedule: FEE SCHEDULE] [Reference Lab Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 64.9] [Physical Therapy (%BC): 64.9] [Respiratory Services/Therapy (%BC): 64.9] [Speech Therapy (%BC): 64.9] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 63.9] [All Other OP (%BC): 64.9]" } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "009", "type": "MS-DRG" } ], "description": "Bone marrow transplant", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "043", "type": "MS-DRG" } ], "description": "Hyphema", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "044", "type": "MS-DRG" } ], "description": "Acute Major Eye Infections", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "045", "type": "MS-DRG" } ], "description": "Neurological eye disorders", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "046", "type": "MS-DRG" } ], "description": "Other Disorders of the Eye Age >17 w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "047", "type": "MS-DRG" } ], "description": "Other Disorders of the Eye Age >17 w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "048", "type": "MS-DRG" } ], "description": "Other Disorders of the Eye Age 0-17", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "049", "type": "MS-DRG" } ], "description": "Major Head & Neck Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "050", "type": "MS-DRG" } ], "description": "Sialoadenectomy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "051", "type": "MS-DRG" } ], "description": "Salivary Gland Procedures Except Sialoadenectomy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "104", "type": "MS-DRG" } ], "description": "Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "105", "type": "MS-DRG" } ], "description": "Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "106", "type": "MS-DRG" } ], "description": "Coronary Bypass w PTCA", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "107", "type": "MS-DRG" } ], "description": "No Longer Valid", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "108", "type": "MS-DRG" } ], "description": "Other Cardiothoracic Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "109", "type": "MS-DRG" } ], "description": "No Longer Valid", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "110", "type": "MS-DRG" } ], "description": "Major Cardiovascular Procedures w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "111", "type": "MS-DRG" } ], "description": "Major Cardiovascular Procedures w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "112", "type": "MS-DRG" } ], "description": "No Longer Valid", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "118", "type": "MS-DRG" } ], "description": "Cardiac Pacemaker Device Replacement", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "119", "type": "MS-DRG" } ], "description": "Vein ligation & stripping", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "120", "type": "MS-DRG" } ], "description": "Other circulatory system O.R. procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "126", "type": "MS-DRG" } ], "description": "Acute & Subacute Endocarditis", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "127", "type": "MS-DRG" } ], "description": "Heart Failure & Shock", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "128", "type": "MS-DRG" } ], "description": "Deep Vein Thrombophlebitis", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "129", "type": "MS-DRG" } ], "description": "Major Head & Neck Procedures W Cc/Mcc Or Major Device", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "130", "type": "MS-DRG" } ], "description": "Major Head & Neck Procedures W/O Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "131", "type": "MS-DRG" } ], "description": "Cranial/Facial Procedures W Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "132", "type": "MS-DRG" } ], "description": "Cranial/Facial Procedures W/O Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "133", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "134", "type": "MS-DRG" } ], "description": "Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "160", "type": "MS-DRG" } ], "description": "Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "161", "type": "MS-DRG" } ], "description": "Inguinal & Femoral Hernia Procedures Age >17 w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "162", "type": "MS-DRG" } ], "description": "Inguinal & Femoral Hernia Procedures Age >17 w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "169", "type": "MS-DRG" } ], "description": "Mouth Procedures w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "171", "type": "MS-DRG" } ], "description": "Other Digestive System O.R. Procedures w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "174", "type": "MS-DRG" } ], "description": "G.I. hemorrhage w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "209", "type": "MS-DRG" } ], "description": "Complex Aortic Arch Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 78483.7, "90th_percentile": 78483.7, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 78483.7, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" }, { "billing_class": "facility", "maximum": 89110.28, "minimum": 89110.28, "payers_information": [ { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89110.28 } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "210", "type": "MS-DRG" } ], "description": "Hip & Femur Procedures Except Major Joint Age >17 w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "211", "type": "MS-DRG" } ], "description": "Hip & Femur Procedures Except Major Joint Age >17 w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "213", "type": "MS-DRG" } ], "description": "Endovascular Abdominal Aorta With Iliac Branch Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 4082.67, "90th_percentile": 4082.67, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 4082.67, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 44637.9, "90th_percentile": 44637.9, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 44637.9, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" }, { "billing_class": "facility", "maximum": 45529.32, "minimum": 45529.32, "payers_information": [ { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45529.32 } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "214", "type": "MS-DRG" } ], "description": "No Longer Valid", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "222", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "223", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "224", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "225", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "226", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "227", "type": "MS-DRG" } ], "description": "Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "230", "type": "MS-DRG" } ], "description": "Other cardiothoracic procedures w/o CC/MCC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "237", "type": "MS-DRG" } ], "description": "Major cardiovasc procedures w MCC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "238", "type": "MS-DRG" } ], "description": "Major cardiovasc procedures w/o MCC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "246", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "247", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "248", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "249", "type": "MS-DRG" } ], "description": "Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "318", "type": "MS-DRG" } ], "description": "Percutaneous Coronary Atherectomy Without Intraluminal Device", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 17818.74, "90th_percentile": 17818.74, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 17818.74, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 50507.71, "90th_percentile": 50507.71, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 50507.71, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" }, { "billing_class": "facility", "maximum": 20020.95, "minimum": 20020.95, "payers_information": [ { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20020.95 } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "338", "type": "MS-DRG" } ], "description": "Appendectomy With Complicated Principal Diagnosis With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "339", "type": "MS-DRG" } ], "description": "Appendectomy With Complicated Principal Diagnosis With Cc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "340", "type": "MS-DRG" } ], "description": "Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "341", "type": "MS-DRG" } ], "description": "Appendectomy Without Complicated Principal Diagnosis With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "342", "type": "MS-DRG" } ], "description": "Appendectomy Without Complicated Principal Diagnosis With Cc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "343", "type": "MS-DRG" } ], "description": "Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "359", "type": "MS-DRG" } ], "description": "Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 69134.25, "90th_percentile": 69134.25, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 69134.25, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 27118.31, "90th_percentile": 27367.4, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 27118.31, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "10th_percentile": 66685.96, "90th_percentile": 66685.96, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 66685.96, "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" }, { "billing_class": "facility", "maximum": 27914.12, "minimum": 27914.12, "payers_information": [ { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27914.12 } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "360", "type": "MS-DRG" } ], "description": "Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "10th_percentile": 64984.77, "90th_percentile": 64984.77, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 64984.77, "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 19390.11, "90th_percentile": 19390.11, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 19390.11, "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 49739.41, "90th_percentile": 49739.41, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 49739.41, "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "10th_percentile": 18392.52, "90th_percentile": 18392.52, "additional_payer_notes": "Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer\u2019s algorithm.", "count": "1 through 10", "median_amount": 18392.52, "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" }, { "billing_class": "facility", "maximum": 19959.6, "minimum": 19959.6, "payers_information": [ { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Cigna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 }, { "additional_payer_notes": "MSDRG Base Rate", "methodology": "fee schedule", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19959.6 } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "361", "type": "MS-DRG" } ], "description": "Laparoscopy & Incisional Tubal Interruption", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "362", "type": "MS-DRG" } ], "description": "Endoscopic Tubal Interruption", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "363", "type": "MS-DRG" } ], "description": "D&C, Conization & Radio-Implant, for Malignancy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "364", "type": "MS-DRG" } ], "description": "D&C, Conization Except for Malignancy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "365", "type": "MS-DRG" } ], "description": "Other Female Reproductive System O.R. Procedures", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "366", "type": "MS-DRG" } ], "description": "Malignancy, female reproductive system w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "367", "type": "MS-DRG" } ], "description": "Malignancy, Female Reproductive System w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "396", "type": "MS-DRG" } ], "description": "Red Blood Cell Disorders Age 0-17", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "400", "type": "MS-DRG" } ], "description": "No Longer Valid", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "401", "type": "MS-DRG" } ], "description": "Lymphoma & non-acute leukemia w other O.R. proc w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "403", "type": "MS-DRG" } ], "description": "Lymphoma & non-acute leukemia w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "404", "type": "MS-DRG" } ], "description": "Lymphoma & Non-Acute Leukemia w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "431", "type": "MS-DRG" } ], "description": "Childhood Mental Disorders", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "449", "type": "MS-DRG" } ], "description": "Poisoning & toxic Effects of Drugs Age >17 w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "452", "type": "MS-DRG" } ], "description": "Complications of treatment w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "453", "type": "MS-DRG" } ], "description": "Combined Anterior And Posterior Spinal Fusion With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "459", "type": "MS-DRG" } ], "description": "Spinal Fusion Except Cervical With Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "484", "type": "MS-DRG" } ], "description": "Major joint & limb reattachment proc of upper extremity w/o CC/MCC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "490", "type": "MS-DRG" } ], "description": "Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "491", "type": "MS-DRG" } ], "description": "Back & neck proc exc spinal fusion w/o CC/MCC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "523", "type": "MS-DRG" } ], "description": "Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "524", "type": "MS-DRG" } ], "description": "Transient ischemia", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "525", "type": "MS-DRG" } ], "description": "Other heart assist system implant", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "526", "type": "MS-DRG" } ], "description": "No Longer Valid", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "527", "type": "MS-DRG" } ], "description": "No Longer Valid", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "528", "type": "MS-DRG" } ], "description": "Intracranial Vascular Proc w Pdx Hemorrhage", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "529", "type": "MS-DRG" } ], "description": "Ventricular shunt procedures w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "530", "type": "MS-DRG" } ], "description": "Ventricular Shunt Procedures w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "531", "type": "MS-DRG" } ], "description": "Spinal Procedures w CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "532", "type": "MS-DRG" } ], "description": "Spinal Procedures w/o CC", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "567", "type": "MS-DRG" } ], "description": "Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "568", "type": "MS-DRG" } ], "description": "Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "569", "type": "MS-DRG" } ], "description": "Major Small & Large Bowel Procedures w CC w Major Gi Dx", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "685", "type": "MS-DRG" } ], "description": "Admit For Renal Dialysis", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "691", "type": "MS-DRG" } ], "description": "Urinary Stones W Esw Lithotripsy W Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "692", "type": "MS-DRG" } ], "description": "Urinary Stones W Esw Lithotripsy W/O Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "765", "type": "MS-DRG" } ], "description": "Cesarean Section W Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "766", "type": "MS-DRG" } ], "description": "Cesarean Section W/O Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "767", "type": "MS-DRG" } ], "description": "Vaginal Delivery W Sterilization &/Or D&C", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "774", "type": "MS-DRG" } ], "description": "Vaginal Delivery W Complicating Diagnoses", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "775", "type": "MS-DRG" } ], "description": "Vaginal Delivery W/O Complicating Diagnoses", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "777", "type": "MS-DRG" } ], "description": "Ectopic Pregnancy", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "778", "type": "MS-DRG" } ], "description": "Threatened Abortion", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "780", "type": "MS-DRG" } ], "description": "False Labor", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "781", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses W Medical Complications", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "782", "type": "MS-DRG" } ], "description": "Other Antepartum Diagnoses W/O Medical Complications", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "984", "type": "MS-DRG" } ], "description": "Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "985", "type": "MS-DRG" } ], "description": "Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "986", "type": "MS-DRG" } ], "description": "Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "998", "type": "MS-DRG" } ], "description": "Principal Diagnosis Invalid As Discharge Diagnosis", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "999", "type": "MS-DRG" } ], "description": "Ungroupable", "standard_charges": [ { "billing_class": "facility", "payers_information": [ { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 184050 | Total % of Charge: 72.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13815 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 11424 Days: 2] [Alcohol/ Chemical Dependency-Per Diem: 3112] [Psych-Per Diem: 3112] [Rehab-Per Diem: 3201] [IP Prosthetics/Implants/Devices (%BC): 65.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Aetna", "plan_name": "Meritain/Asa Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 76.4] [All Other IP (%BC): 76.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Allwell", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Amerihealth", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Blue Access Hmo/Ppo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 206987 | Total % of Charge: 100] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3574] [Psych-Per Diem: 3574]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Medicare Managed Care Plan", "standard_charge_algorithm": "[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Anthem Traditional", "standard_charge_algorithm": "[All IP services (%BC): 100] [All Other IP (%BC): 100]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Bcbs", "plan_name": "Pathway Exchange", "standard_charge_algorithm": "[All IP services (%BC): 34.4] [All Other IP (%BC): 34.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Buckeye Community Health Plan", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 36] [All Other IP (%BC): 36]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Caresource", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Great West Other Commercial Plan", "standard_charge_algorithm": "[All IP services (%BC): 82.9] [All Other IP (%BC): 82.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Hmo", "standard_charge_algorithm": "[Stop Loss: Total Charges > 94706 | Total % of Charge: 70.6] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13537 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 10657 Days: 2] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Cigna", "plan_name": "Ppo", "standard_charge_algorithm": "[All IP services (%BC): 80.9] [All Other IP (%BC): 80.9]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Devoted Health", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "First Health/Coventry", "plan_name": "First Health All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 94] [All Other IP (%BC): 94]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Humana", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 186902 | Total % of Charge: 85.7] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 3211] [Psych-Per Diem: 3211] [IP Prosthetics/Implants/Devices (%BC): 65.5]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Exchange", "standard_charge_algorithm": "[All IP services (%BC): 35.4] [All Other IP (%BC): 35.4]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medical Mutual Of Ohio", "plan_name": "Traditional", "standard_charge_algorithm": "[All IP services (%BC): 87.7] [All Other IP (%BC): 87.7]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Medigold", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Molina", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Ohio Health Choice Plan", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[All IP services (%BC): 95] [All Other IP (%BC): 95]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "The Health Plan", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "All Commercial Plans", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 78.3] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 13642 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 13642 Days: 2] [Rehab-Per Diem: 2659] [Hospice-Per Diem: 1632] [IP Prosthetics/Implants/Devices (%BC): 65.1]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicaid Managed Care Plan", "standard_charge_algorithm": "[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://medicaid.ohio.gov/resources-for-providers/enrollment-and-support/provider-types/hospital-provider-information/hospital-payment-policy]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Medicare Managed Care Plan", "standard_charge_algorithm": "[MSDRG Base Rate: FEE SCHEDULE]" }, { "additional_payer_notes": "No services performed during 15-month lookback period.", "count": "0", "methodology": "other", "payer_name": "Unitedhealthcare", "plan_name": "Options Other Commercial Plan", "standard_charge_algorithm": "[Stop Loss: Total Charges > 185302 | Total % of Charge: 82.9] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 3 day stay-Case Rate: 14492 Days: 3] [Normal vag. Del. 2 day stay-Case Rate: 14492 Days: 2] [Rehab-Per Diem: 2816] [Hospice-Per Diem: 1729] [IP Prosthetics/Implants/Devices (%BC): 69.1]" } ], "setting": "inpatient" } ] }, { "code_information": [ { "code": "0648T", "type": "HCPCS" } ], "description": "Quan mr alys tiss w/o mri", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0649T", "type": "HCPCS" } ], "description": "Quan mr alys tiss w/mri", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0697T", "type": "HCPCS" } ], "description": "Quan mr tis wo mri mlt orgn", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0698T", "type": "HCPCS" } ], "description": "Quan mr tiss w/mri mlt orgn", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0723T", "type": "HCPCS" } ], "description": "Qmrcp w/o dx mri sm anat ses", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0724T", "type": "HCPCS" } ], "description": "Qmrcp w/dx mri same anatomy", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0889T", "type": "HCPCS" } ], "description": "Prsnlz trgt dvl arhfcmrigtbs", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75577", "type": "HCPCS" } ], "description": "Quan&char c athrosclrtc plaq", "standard_charges": [ { "billing_class": "facility", "maximum": 897.06, "minimum": 897.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0562", "type": "HCPCS" } ], "description": "Complex simulation w/pet-ct", "standard_charges": [ { "billing_class": "facility", "maximum": 1840.84, "minimum": 1840.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1840.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78431", "type": "HCPCS" } ], "description": "Myocrd img pet rst&strs ct", "standard_charges": [ { "billing_class": "facility", "maximum": 2123.98, "minimum": 2123.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2123.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78433", "type": "HCPCS" } ], "description": "Myocrd img pet 2rtracer ct", "standard_charges": [ { "billing_class": "facility", "maximum": 2123.98, "minimum": 2123.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2123.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64654", "type": "HCPCS" } ], "description": "1st opn implt bat modulj sys", "standard_charges": [ { "billing_class": "facility", "maximum": 42470.57, "minimum": 42470.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42470.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C2616", "type": "HCPCS" } ], "description": "Brachytx, non-str,Yttrium-90", "standard_charges": [ { "billing_class": "facility", "maximum": 17771.01, "minimum": 17771.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17771.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0811T", "type": "HCPCS" } ], "description": "Rem mlt day uroflow setup", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0982T", "type": "HCPCS" } ], "description": "Rem mntr impl ivc snr set-up", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1008T", "type": "HCPCS" } ], "description": "Rem mntr s-scl eeg sys setup", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92002", "type": "HCPCS" } ], "description": "Eye exam new patient", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92004", "type": "HCPCS" } ], "description": "Eye exam new patient", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92012", "type": "HCPCS" } ], "description": "Eye exam establish patient", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92014", "type": "HCPCS" } ], "description": "Eye exam&tx estab pt 1/>vst", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95250", "type": "HCPCS" } ], "description": "Glucose monitoring cont", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98975", "type": "HCPCS" } ], "description": "Rem ther mntr 1st setup&edu", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99453", "type": "HCPCS" } ], "description": "Rem mntr physiol param setup", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99460", "type": "HCPCS" } ], "description": "Init nb em per day hosp", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99463", "type": "HCPCS" } ], "description": "Same day nb discharge", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99495", "type": "HCPCS" } ], "description": "Trans care mgmt 14 day disch", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99496", "type": "HCPCS" } ], "description": "Trans care mgmt 7 day disch", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0120", "type": "HCPCS" } ], "description": "Periodic oral evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0140", "type": "HCPCS" } ], "description": "Limit oral eval problm focus", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0150", "type": "HCPCS" } ], "description": "Comprehensve oral evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0160", "type": "HCPCS" } ], "description": "Extensv oral eval prob focus", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0170", "type": "HCPCS" } ], "description": "Re-eval,est pt,problem focus", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0171", "type": "HCPCS" } ], "description": "Re-eval post-op visit", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0180", "type": "HCPCS" } ], "description": "Comp periodontal evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0191", "type": "HCPCS" } ], "description": "Assessment of a patient", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1110", "type": "HCPCS" } ], "description": "Dental prophylaxis adult", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4921", "type": "HCPCS" } ], "description": "Gingival irrigation per quad", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0245", "type": "HCPCS" } ], "description": "Initial foot exam pt lops", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0246", "type": "HCPCS" } ], "description": "Followup eval of foot pt lop", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0248", "type": "HCPCS" } ], "description": "Demonstrate use home inr mon", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0249", "type": "HCPCS" } ], "description": "Provide INR test mater/equip", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0402", "type": "HCPCS" } ], "description": "Initial preventive exam", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0463", "type": "HCPCS" } ], "description": "Hospital outpt clinic visit", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0552", "type": "HCPCS" } ], "description": "Supply of digital device", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0553", "type": "HCPCS" } ], "description": "Monthly tx for dmht 20mins", "standard_charges": [ { "billing_class": "facility", "maximum": 128.37, "minimum": 128.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99281", "type": "HCPCS" } ], "description": "Emergency dept visit", "standard_charges": [ { "billing_class": "facility", "maximum": 81.31, "minimum": 81.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99282", "type": "HCPCS" } ], "description": "Emergency dept visit", "standard_charges": [ { "billing_class": "facility", "maximum": 148.05, "minimum": 148.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 148.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99283", "type": "HCPCS" } ], "description": "Emergency dept visit", "standard_charges": [ { "billing_class": "facility", "maximum": 263.21, "minimum": 263.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 263.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90945", "type": "HCPCS" } ], "description": "Dialysis one evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 402.33, "minimum": 402.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 402.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99284", "type": "HCPCS" } ], "description": "Emergency dept visit", "standard_charges": [ { "billing_class": "facility", "maximum": 402.33, "minimum": 402.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 402.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0175", "type": "HCPCS" } ], "description": "Opps service,sched team conf", "standard_charges": [ { "billing_class": "facility", "maximum": 402.33, "minimum": 402.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 402.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99285", "type": "HCPCS" } ], "description": "Emergency dept visit", "standard_charges": [ { "billing_class": "facility", "maximum": 574.22, "minimum": 574.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 574.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0379", "type": "HCPCS" } ], "description": "Direct refer hospital observ", "standard_charges": [ { "billing_class": "facility", "maximum": 574.22, "minimum": 574.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 574.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99291", "type": "HCPCS" } ], "description": "Critical care first hour", "standard_charges": [ { "billing_class": "facility", "maximum": 796.47, "minimum": 796.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 796.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0390", "type": "HCPCS" } ], "description": "Trauma Respons w/hosp criti", "standard_charges": [ { "billing_class": "facility", "maximum": 1285.22, "minimum": 1285.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1285.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0906T", "type": "HCPCS" } ], "description": "Coms ther 1st appl<=50 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 193.46, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96567", "type": "HCPCS" } ], "description": "Photodynamic tx skin", "standard_charges": [ { "billing_class": "facility", "maximum": 193.46, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96573", "type": "HCPCS" } ], "description": "Pdt dstr prmlg les phys/qhp", "standard_charges": [ { "billing_class": "facility", "maximum": 193.46, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96999", "type": "HCPCS" } ], "description": "Dermatological procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 193.46, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97605", "type": "HCPCS" } ], "description": "Neg press wound tx <=50 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 193.46, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97610", "type": "HCPCS" } ], "description": "Low frequency non-thermal us", "standard_charges": [ { "billing_class": "facility", "maximum": 193.46, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0247", "type": "HCPCS" } ], "description": "Routine footcare pt w lops", "standard_charges": [ { "billing_class": "facility", "maximum": 193.46, "minimum": 193.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0973T", "type": "HCPCS" } ], "description": "Slctv nzmtc dbrdmt t/a/l 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 391.97, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0975T", "type": "HCPCS" } ], "description": "Slctv nzmtc dbrdmt s/n/hf 1", "standard_charges": [ { "billing_class": "facility", "maximum": 391.97, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96913", "type": "HCPCS" } ], "description": "Photochemotherapy uv-a or b", "standard_charges": [ { "billing_class": "facility", "maximum": 391.97, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97606", "type": "HCPCS" } ], "description": "Neg press wound tx >50 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 391.97, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97607", "type": "HCPCS" } ], "description": "Neg press wnd tx <=50 sq cm", "standard_charges": [ { "billing_class": "facility", "maximum": 391.97, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97608", "type": "HCPCS" } ], "description": "Neg press wound tx >50 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 391.97, "minimum": 391.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0429", "type": "HCPCS" } ], "description": "Dermal filler injection(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 1989.46, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0460", "type": "HCPCS" } ], "description": "Autologous PRP for ulcers", "standard_charges": [ { "billing_class": "facility", "maximum": 1989.46, "minimum": 1989.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1989.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0277", "type": "HCPCS" } ], "description": "Hbot, full body chamber, 30m", "standard_charges": [ { "billing_class": "facility", "maximum": 132.69, "minimum": 132.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 132.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7510", "type": "HCPCS" } ], "description": "I&d absc intraoral soft tiss", "standard_charges": [ { "billing_class": "facility", "maximum": 682.8, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7511", "type": "HCPCS" } ], "description": "Incision/drain abscess intra", "standard_charges": [ { "billing_class": "facility", "maximum": 682.8, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7520", "type": "HCPCS" } ], "description": "I&d abscess extraoral", "standard_charges": [ { "billing_class": "facility", "maximum": 682.8, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7521", "type": "HCPCS" } ], "description": "Incision/drain abscess extra", "standard_charges": [ { "billing_class": "facility", "maximum": 682.8, "minimum": 682.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 682.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0959T", "type": "HCPCS" } ], "description": "Rmv/rplc magnet coil assem", "standard_charges": [ { "billing_class": "facility", "maximum": 1592.51, "minimum": 1592.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0970T", "type": "HCPCS" } ], "description": "Ablt b9 brst tum perq lsr ea", "standard_charges": [ { "billing_class": "facility", "maximum": 3775.35, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0971T", "type": "HCPCS" } ], "description": "Ablt mal brst tum pq lsr uni", "standard_charges": [ { "billing_class": "facility", "maximum": 3775.35, "minimum": 3775.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1019T", "type": "HCPCS" } ], "description": "Lymphovenous bypass per xtr", "standard_charges": [ { "billing_class": "facility", "maximum": 6402.59, "minimum": 6402.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6402.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0957T", "type": "HCPCS" } ], "description": "Rev s-sclp eltr ra rcvr&tlmt", "standard_charges": [ { "billing_class": "facility", "maximum": 1550.46, "minimum": 1550.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1550.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0958T", "type": "HCPCS" } ], "description": "Rmv s-sclp eltr ra rcvr&tlmt", "standard_charges": [ { "billing_class": "facility", "maximum": 3154.93, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7874", "type": "HCPCS" } ], "description": "Tmj arthroscopy disc reposit", "standard_charges": [ { "billing_class": "facility", "maximum": 3154.93, "minimum": 3154.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3154.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27458", "type": "HCPCS" } ], "description": "Osteot femur imed lngth dev", "standard_charges": [ { "billing_class": "facility", "maximum": 6996.6, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "27713", "type": "HCPCS" } ], "description": "Osteot tibia imed lngth dev", "standard_charges": [ { "billing_class": "facility", "maximum": 6996.6, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "62330", "type": "HCPCS" } ], "description": "Dcmprn prq rmv lig flv 1lmbr", "standard_charges": [ { "billing_class": "facility", "maximum": 6996.6, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0276", "type": "HCPCS" } ], "description": "Pild/placebo control clin tr", "standard_charges": [ { "billing_class": "facility", "maximum": 6996.6, "minimum": 6996.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6996.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1003T", "type": "HCPCS" } ], "description": "Arthrp 1st crp/mtcrpl prostc", "standard_charges": [ { "billing_class": "facility", "maximum": 12379.34, "minimum": 12379.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12379.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92511", "type": "HCPCS" } ], "description": "Nasopharyngoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 192.47, "minimum": 192.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4999", "type": "HCPCS" } ], "description": "Unspecified periodontal proc", "standard_charges": [ { "billing_class": "facility", "maximum": 228.38, "minimum": 228.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92502", "type": "HCPCS" } ], "description": "Ear and throat examination", "standard_charges": [ { "billing_class": "facility", "maximum": 520.03, "minimum": 520.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 520.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9727", "type": "HCPCS" } ], "description": "Insert palate implants", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4231", "type": "HCPCS" } ], "description": "Ana crown exp 1-3 per quad", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4241", "type": "HCPCS" } ], "description": "Gngvl flap w rootplan 1-3 th", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4245", "type": "HCPCS" } ], "description": "Apically positioned flap", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4266", "type": "HCPCS" } ], "description": "Guided tiss regen resorble", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4267", "type": "HCPCS" } ], "description": "Guided tiss regen nonresorb", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4270", "type": "HCPCS" } ], "description": "Pedicle soft tissue graft pr", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4273", "type": "HCPCS" } ], "description": "Auto tissue graft 1st tooth", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4275", "type": "HCPCS" } ], "description": "Non-auto graft 1st tooth", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4276", "type": "HCPCS" } ], "description": "Con tissue w dble ped graft", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4277", "type": "HCPCS" } ], "description": "Soft tissue graft firsttooth", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7210", "type": "HCPCS" } ], "description": "Rem imp tooth w mucoper flp", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7251", "type": "HCPCS" } ], "description": "Coronectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7310", "type": "HCPCS" } ], "description": "Alveoplasty w/ extraction", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7311", "type": "HCPCS" } ], "description": "Alveoloplasty w/extract 1-3", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7320", "type": "HCPCS" } ], "description": "Alveoplasty w/o extraction", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7321", "type": "HCPCS" } ], "description": "Alveoloplasty not w/extracts", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7410", "type": "HCPCS" } ], "description": "Rad exc lesion up to 1.25 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7411", "type": "HCPCS" } ], "description": "Excision benign lesion>1.25c", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7412", "type": "HCPCS" } ], "description": "Excision benign lesion compl", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7413", "type": "HCPCS" } ], "description": "Excision malig lesion<=1.25c", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7414", "type": "HCPCS" } ], "description": "Excision malig lesion>1.25cm", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7415", "type": "HCPCS" } ], "description": "Excision malig les complicat", "standard_charges": [ { "billing_class": "facility", "maximum": 1496.07, "minimum": 1496.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1496.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0964T", "type": "HCPCS" } ], "description": "I&cust prep jaw xpnsj 1arch", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0965T", "type": "HCPCS" } ], "description": "I&cst prp jw xpn dl arch non", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0966T", "type": "HCPCS" } ], "description": "I&cst prp jw xpn dl arch fxd", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4210", "type": "HCPCS" } ], "description": "Gingivectomy/plasty 4 or mor", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4211", "type": "HCPCS" } ], "description": "Gingivectomy/plasty 1 to 3", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4212", "type": "HCPCS" } ], "description": "Gingivectomy/plasty rest", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4230", "type": "HCPCS" } ], "description": "Ana crown exp 4 or> per quad", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4240", "type": "HCPCS" } ], "description": "Gingival flap proc w/ planin", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4261", "type": "HCPCS" } ], "description": "Osseous surg 1 to 3 teeth", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7440", "type": "HCPCS" } ], "description": "Malig tumor exc to 1.25 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7441", "type": "HCPCS" } ], "description": "Malig tumor > 1.25 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7450", "type": "HCPCS" } ], "description": "Rem odontogen cyst to 1.25cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7451", "type": "HCPCS" } ], "description": "Rem odontogen cyst > 1.25 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7471", "type": "HCPCS" } ], "description": "Rem exostosis any site", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7670", "type": "HCPCS" } ], "description": "Closd rductn splint alveolus", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7771", "type": "HCPCS" } ], "description": "Alveolus clsd reduc stblz te", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0330", "type": "HCPCS" } ], "description": "Facility svs dental rehab", "standard_charges": [ { "billing_class": "facility", "maximum": 3196.84, "minimum": 3196.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3196.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4260", "type": "HCPCS" } ], "description": "Osseous surgery 4 or more", "standard_charges": [ { "billing_class": "facility", "maximum": 5708.03, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7340", "type": "HCPCS" } ], "description": "Vestibuloplasty ridge extens", "standard_charges": [ { "billing_class": "facility", "maximum": 5708.03, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7350", "type": "HCPCS" } ], "description": "Vestibuloplasty exten graft", "standard_charges": [ { "billing_class": "facility", "maximum": 5708.03, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7485", "type": "HCPCS" } ], "description": "Surg reduct osseoustuberosit", "standard_charges": [ { "billing_class": "facility", "maximum": 5708.03, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7671", "type": "HCPCS" } ], "description": "Alveolus open reduction", "standard_charges": [ { "billing_class": "facility", "maximum": 5708.03, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7770", "type": "HCPCS" } ], "description": "Open reduc compd alveolus fx", "standard_charges": [ { "billing_class": "facility", "maximum": 5708.03, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7950", "type": "HCPCS" } ], "description": "Mandible graft", "standard_charges": [ { "billing_class": "facility", "maximum": 5708.03, "minimum": 5708.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5708.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1021T", "type": "HCPCS" } ], "description": "Active thrc irrigation spx", "standard_charges": [ { "billing_class": "facility", "maximum": 604.86, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75801", "type": "HCPCS" } ], "description": "Lymph vessel x-ray arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 604.86, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75872", "type": "HCPCS" } ], "description": "Vein x-ray skull epidural", "standard_charges": [ { "billing_class": "facility", "maximum": 604.86, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75880", "type": "HCPCS" } ], "description": "Vein x-ray eye socket", "standard_charges": [ { "billing_class": "facility", "maximum": 604.86, "minimum": 604.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 604.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75803", "type": "HCPCS" } ], "description": "Lymph vessel x-ray arms/legs", "standard_charges": [ { "billing_class": "facility", "maximum": 1517.83, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75820", "type": "HCPCS" } ], "description": "Vein x-ray arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 1517.83, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75822", "type": "HCPCS" } ], "description": "Vein x-ray arms/legs", "standard_charges": [ { "billing_class": "facility", "maximum": 1517.83, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75827", "type": "HCPCS" } ], "description": "Vein x-ray chest", "standard_charges": [ { "billing_class": "facility", "maximum": 1517.83, "minimum": 1517.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1517.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75600", "type": "HCPCS" } ], "description": "Contrast exam thoracic aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75625", "type": "HCPCS" } ], "description": "Contrast exam abdominl aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75630", "type": "HCPCS" } ], "description": "X-ray aorta leg arteries", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75710", "type": "HCPCS" } ], "description": "Artery x-rays arm/leg", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75716", "type": "HCPCS" } ], "description": "Artery x-rays arms/legs", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75731", "type": "HCPCS" } ], "description": "Artery x-rays adrenal gland", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75733", "type": "HCPCS" } ], "description": "Artery x-rays adrenals", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75741", "type": "HCPCS" } ], "description": "Artery x-rays lung", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75743", "type": "HCPCS" } ], "description": "Artery x-rays lungs", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75746", "type": "HCPCS" } ], "description": "Artery x-rays lung", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75756", "type": "HCPCS" } ], "description": "Artery x-rays chest", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75805", "type": "HCPCS" } ], "description": "Lymph vessel x-ray trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75807", "type": "HCPCS" } ], "description": "Lymph vessel x-ray trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75810", "type": "HCPCS" } ], "description": "Vein x-ray spleen/liver", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75825", "type": "HCPCS" } ], "description": "Vein x-ray trunk", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75831", "type": "HCPCS" } ], "description": "Vein x-ray kidney", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75833", "type": "HCPCS" } ], "description": "Vein x-ray kidneys", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75840", "type": "HCPCS" } ], "description": "Vein x-ray adrenal gland", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75860", "type": "HCPCS" } ], "description": "Vein x-ray neck", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75870", "type": "HCPCS" } ], "description": "Vein x-ray skull", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75885", "type": "HCPCS" } ], "description": "Vein x-ray liver w/hemodynam", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75887", "type": "HCPCS" } ], "description": "Vein x-ray liver w/o hemodyn", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75889", "type": "HCPCS" } ], "description": "Vein x-ray liver w/hemodynam", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75891", "type": "HCPCS" } ], "description": "Vein x-ray liver", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75898", "type": "HCPCS" } ], "description": "Follow-up angiography", "standard_charges": [ { "billing_class": "facility", "maximum": 3044.51, "minimum": 3044.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3044.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75605", "type": "HCPCS" } ], "description": "Contrast exam thoracic aorta", "standard_charges": [ { "billing_class": "facility", "maximum": 5365.4, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75705", "type": "HCPCS" } ], "description": "Artery x-rays spine", "standard_charges": [ { "billing_class": "facility", "maximum": 5365.4, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75726", "type": "HCPCS" } ], "description": "Artery x-rays abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 5365.4, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75736", "type": "HCPCS" } ], "description": "Artery x-rays pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 5365.4, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75893", "type": "HCPCS" } ], "description": "Venous sampling by catheter", "standard_charges": [ { "billing_class": "facility", "maximum": 5365.4, "minimum": 5365.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5365.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37254", "type": "HCPCS" } ], "description": "Revsc evasc ivt angio sf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 5487.93, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37256", "type": "HCPCS" } ], "description": "Revsc evasc ivt angio cplx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 5487.93, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37263", "type": "HCPCS" } ], "description": "Revsc evasc fpvt angio sf 1", "standard_charges": [ { "billing_class": "facility", "maximum": 5487.93, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37265", "type": "HCPCS" } ], "description": "Revsc evsc fpvt angio cplx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 5487.93, "minimum": 5487.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5487.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0913T", "type": "HCPCS" } ], "description": "Prq tcat ther rx ntrac balo1", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37258", "type": "HCPCS" } ], "description": "Revsc evasc ivt stent sf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37260", "type": "HCPCS" } ], "description": "Revsc evasc ivt st cplx 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37267", "type": "HCPCS" } ], "description": "Revsc evsc fpvt stent sf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37269", "type": "HCPCS" } ], "description": "Revsc evasc fpvt st cplx 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37280", "type": "HCPCS" } ], "description": "Revsc evsc tpvt angio sf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37282", "type": "HCPCS" } ], "description": "Rvsc evsc tpvt angio cplx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37296", "type": "HCPCS" } ], "description": "Revsc evasc imvt angio sf 1", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37298", "type": "HCPCS" } ], "description": "Revsc evsc imvt angio cplx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92945", "type": "HCPCS" } ], "description": "Prq trl rvs ch occ ant&rtrgr", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92997", "type": "HCPCS" } ], "description": "Pul art balloon repr percut", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8004", "type": "HCPCS" } ], "description": "Sim ang w/prs cath rad emb", "standard_charges": [ { "billing_class": "facility", "maximum": 11131.16, "minimum": 11131.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11131.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0981T", "type": "HCPCS" } ], "description": "Tcat impl wrls ivc snr", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37271", "type": "HCPCS" } ], "description": "Revsc evsc fpvt athrc sf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37273", "type": "HCPCS" } ], "description": "Revsc evsc fpvt athrc cplx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37275", "type": "HCPCS" } ], "description": "Rvsc evsc fpvt st athrc sf 1", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37277", "type": "HCPCS" } ], "description": "Rvsc evsc fpvt st athr cpx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37284", "type": "HCPCS" } ], "description": "Revsc evasc tpvt st sf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37286", "type": "HCPCS" } ], "description": "Revsc evasc tpvt st cplx 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37288", "type": "HCPCS" } ], "description": "Revsc evsc tpvt athrc sf 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "37290", "type": "HCPCS" } ], "description": "Revsc evsc tpvt athrc cplx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 17675.76, "minimum": 17675.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17675.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": 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"Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93602", "type": "HCPCS" } ], "description": "Intra-atrial recording", "standard_charges": [ { "billing_class": "facility", "maximum": 7520.61, "minimum": 7520.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93610", "type": "HCPCS" } ], "description": "Intra-atrial pacing", "standard_charges": [ { "billing_class": "facility", "maximum": 7520.61, "minimum": 7520.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93612", "type": "HCPCS" } ], "description": "Intraventricular pacing", "standard_charges": [ { "billing_class": "facility", "maximum": 7520.61, "minimum": 7520.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93619", "type": "HCPCS" } ], "description": "Electrophysiology evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 7520.61, "minimum": 7520.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93620", "type": "HCPCS" } ], "description": "Electrophysiology evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 7520.61, "minimum": 7520.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93624", "type": "HCPCS" } ], "description": "Electrophysiologic study", "standard_charges": [ { "billing_class": "facility", "maximum": 7520.61, "minimum": 7520.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7520.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0692T", "type": "HCPCS" } ], "description": "Therapeutic ultrafiltration", "standard_charges": [ { "billing_class": "facility", "maximum": 1501.7, "minimum": 1501.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1501.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0651T", "type": "HCPCS" } ], "description": "Mag ctrld capsule endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 874.53, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0977T", "type": "HCPCS" } ], "description": "Upr gi bld detcj snr capsule", "standard_charges": [ { "billing_class": "facility", "maximum": 874.53, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64567", "type": "HCPCS" } ], "description": "Perq elec nrv field stimj cn", "standard_charges": [ { "billing_class": "facility", "maximum": 874.53, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91110", "type": "HCPCS" } ], "description": "Gi tract capsule endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 874.53, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91111", "type": "HCPCS" } ], "description": "Esophageal Capsule Endoscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 874.53, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91112", "type": "HCPCS" } ], "description": "Gi wireless capsule measure", "standard_charges": [ { "billing_class": "facility", "maximum": 874.53, "minimum": 874.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 874.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9777", "type": "HCPCS" } ], "description": "Esophag mucosal integ add-on", "standard_charges": [ { "billing_class": "facility", "maximum": 3717.53, "minimum": 3717.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3717.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91113", "type": "HCPCS" } ], "description": "Gi trc img intral colon i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 896.69, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9725", "type": "HCPCS" } ], "description": "Place endorectal app", "standard_charges": [ { "billing_class": "facility", "maximum": 896.69, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0455", "type": "HCPCS" } ], "description": "Fecal microbiota prep instil", "standard_charges": [ { "billing_class": "facility", "maximum": 896.69, "minimum": 896.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0963T", "type": "HCPCS" } ], "description": "Anosc sbmcsl njx bulking agt", "standard_charges": [ { "billing_class": "facility", "maximum": 1153.83, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0967T", "type": "HCPCS" } ], "description": "Tranal ins tmp clrc anst dev", "standard_charges": [ { "billing_class": "facility", "maximum": 1153.83, "minimum": 1153.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1153.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8006", "type": "HCPCS" } ], "description": "Inst pleu-perit shnt w pump", "standard_charges": [ { "billing_class": "facility", "maximum": 6242.2, "minimum": 6242.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6242.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "43889", "type": "HCPCS" } ], "description": "Gstr rstcv px trnsorl esg", "standard_charges": [ { "billing_class": "facility", "maximum": 10249.52, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "47384", "type": "HCPCS" } ], "description": "Abltj ire liver 1+ tum perq", "standard_charges": [ { "billing_class": "facility", "maximum": 10249.52, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55868", "type": "HCPCS" } ], "description": "Lap srg prst8ct lymph nod bx", "standard_charges": [ { "billing_class": "facility", "maximum": 10249.52, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55869", "type": "HCPCS" } ], "description": "Lap srg prst8ct bi pl lmphad", "standard_charges": [ { "billing_class": "facility", "maximum": 10249.52, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55877", "type": "HCPCS" } ], "description": "Abltj ire prst8 1+ tum perq", "standard_charges": [ { "billing_class": "facility", "maximum": 10249.52, "minimum": 10249.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10249.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0864T", "type": "HCPCS" } ], "description": "Low ntsty eswt corpus cvrnsm", "standard_charges": [ { "billing_class": "facility", "maximum": 240.91, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51725", "type": "HCPCS" } ], "description": "Simple cystometrogram", "standard_charges": [ { "billing_class": "facility", "maximum": 240.91, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51726", "type": "HCPCS" } ], "description": "Complex cystometrogram", "standard_charges": [ { "billing_class": "facility", "maximum": 240.91, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51785", "type": "HCPCS" } ], "description": "Anal/urinary muscle study", "standard_charges": [ { "billing_class": "facility", "maximum": 240.91, "minimum": 240.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 240.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51727", "type": "HCPCS" } ], "description": "Cystometrogram w/up", "standard_charges": [ { "billing_class": "facility", "maximum": 672.35, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51728", "type": "HCPCS" } ], "description": "Cystometrogram w/vp", "standard_charges": [ { "billing_class": "facility", "maximum": 672.35, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51729", "type": "HCPCS" } ], "description": "Cystometrogram w/vp&up", "standard_charges": [ { "billing_class": "facility", "maximum": 672.35, "minimum": 672.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74485", "type": "HCPCS" } ], "description": "X-ray guide gu dilation", "standard_charges": [ { "billing_class": "facility", "maximum": 2015.59, "minimum": 2015.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2015.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55707", "type": "HCPCS" } ], "description": "Bx prst8 trct us guided", "standard_charges": [ { "billing_class": "facility", "maximum": 3398.86, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55708", "type": "HCPCS" } ], "description": "Bx prst8 trct us w/mri fus 1", "standard_charges": [ { "billing_class": "facility", "maximum": 3398.86, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55709", "type": "HCPCS" } ], "description": "Bx prst8 tprnl us guided", "standard_charges": [ { "billing_class": "facility", "maximum": 3398.86, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55710", "type": "HCPCS" } ], "description": "Bx prst8 tprn us w/mri fus 1", "standard_charges": [ { "billing_class": "facility", "maximum": 3398.86, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55711", "type": "HCPCS" } ], "description": "Bx prst8 trct mri-us 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 3398.86, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55712", "type": "HCPCS" } ], "description": "Bx prst8 tprnl mri-us 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 3398.86, "minimum": 3398.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3398.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55713", "type": "HCPCS" } ], "description": "Bx prst8 in-bore ct/mri bx 1", "standard_charges": [ { "billing_class": "facility", "maximum": 5169.96, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "55714", "type": "HCPCS" } ], "description": "Bx prst8 in-bore ct/mri 1", "standard_charges": [ { "billing_class": "facility", "maximum": 5169.96, "minimum": 5169.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5169.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0950T", "type": "HCPCS" } ], "description": "Abltj b9 prst8 tissue hifu", "standard_charges": [ { "billing_class": "facility", "maximum": 9127.77, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0991T", "type": "HCPCS" } ], "description": "Cysto lo-nrg lithtrp&mcrsphr", "standard_charges": [ { "billing_class": "facility", "maximum": 9127.77, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52443", "type": "HCPCS" } ], "description": "Cysto 1st trurl prst8 comis", "standard_charges": [ { "billing_class": "facility", "maximum": 9127.77, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "52597", "type": "HCPCS" } ], "description": "Trurl rbtc wtrjt rescj prst8", "standard_charges": [ { "billing_class": "facility", "maximum": 9127.77, "minimum": 9127.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9127.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90935", "type": "HCPCS" } ], "description": "Hemodialysis one evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 661.76, "minimum": 661.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 661.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0257", "type": "HCPCS" } ], "description": "Unsched dialysis ESRD pt hos", "standard_charges": [ { "billing_class": "facility", "maximum": 661.76, "minimum": 661.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 661.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59020", "type": "HCPCS" } ], "description": "Fetal contract stress test", "standard_charges": [ { "billing_class": "facility", "maximum": 194.94, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59025", "type": "HCPCS" } ], "description": "Fetal non-stress test", "standard_charges": [ { "billing_class": "facility", "maximum": 194.94, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99170", "type": "HCPCS" } ], "description": "Anogenital exam child w imag", "standard_charges": [ { "billing_class": "facility", "maximum": 194.94, "minimum": 194.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "59030", "type": "HCPCS" } ], "description": "Fetal scalp blood sample", "standard_charges": [ { "billing_class": "facility", "maximum": 293.83, "minimum": 293.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 293.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0071T", "type": "HCPCS" } ], "description": "Us leiomyomata ablate <200", "standard_charges": [ { "billing_class": "facility", "maximum": 3121.31, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0072T", "type": "HCPCS" } ], "description": "Us leiomyomata ablate >200", "standard_charges": [ { "billing_class": "facility", "maximum": 3121.31, "minimum": 3121.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3121.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64728", "type": "HCPCS" } ], "description": "Dcmprn median nrv carpl tunl", "standard_charges": [ { "billing_class": "facility", "maximum": 1882.86, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72285", "type": "HCPCS" } ], "description": "Discography cerv/thor spine", "standard_charges": [ { "billing_class": "facility", "maximum": 1882.86, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72295", "type": "HCPCS" } ], "description": "X-ray of lower spine disk", "standard_charges": [ { "billing_class": "facility", "maximum": 1882.86, "minimum": 1882.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1882.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64657", "type": "HCPCS" } ], "description": "Rmvl bat modulj sys tot sys", "standard_charges": [ { "billing_class": "facility", "maximum": 3293.92, "minimum": 3293.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3293.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95991", "type": "HCPCS" } ], "description": "Spin/brain pump refil & main", "standard_charges": [ { "billing_class": "facility", "maximum": 295.97, "minimum": 295.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 295.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0989T", "type": "HCPCS" } ], "description": "Revj/rmvl ins ptn subq&subf", "standard_charges": [ { "billing_class": "facility", "maximum": 3371.02, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1015T", "type": "HCPCS" } ], "description": "Rev/rmv lw esoph sphnc npg/r", "standard_charges": [ { "billing_class": "facility", "maximum": 3371.02, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64655", "type": "HCPCS" } ], "description": "Revj/rplcmt bat mod sys lead", "standard_charges": [ { "billing_class": "facility", "maximum": 3371.02, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64658", "type": "HCPCS" } ], "description": "Rmvl bat modul sys lead only", "standard_charges": [ { "billing_class": "facility", "maximum": 3371.02, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64659", "type": "HCPCS" } ], "description": "Rmvl bat modulj sys pg only", "standard_charges": [ { "billing_class": "facility", "maximum": 3371.02, "minimum": 3371.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3371.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1014T", "type": "HCPCS" } ], "description": "Lap rv/rmv eso sph nstm eltr", "standard_charges": [ { "billing_class": "facility", "maximum": 10744.03, "minimum": 10744.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10744.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1013T", "type": "HCPCS" } ], "description": "Lap srg imp/rpl eso nea&pg/r", "standard_charges": [ { "billing_class": "facility", "maximum": 18706.01, "minimum": 18706.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18706.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "64656", "type": "HCPCS" } ], "description": "Revj/rplcmt bat mod sys pg", "standard_charges": [ { "billing_class": "facility", "maximum": 29753.66, "minimum": 29753.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29753.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92018", "type": "HCPCS" } ], "description": "New eye exam & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 2292.42, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92019", "type": "HCPCS" } ], "description": "Eye exam & treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 2292.42, "minimum": 2292.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2292.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0350T", "type": "HCPCS" } ], "description": "RSA lower extr exam", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0422T", "type": "HCPCS" } ], "description": "Tactile breast img uni/bi", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0558T", "type": "HCPCS" } ], "description": "Ct scan f/biomchn ct alys", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0689T", "type": "HCPCS" } ], "description": "Quan us tis charac w/o dx us", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70030", "type": "HCPCS" } ], "description": "X-ray eye for foreign body", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70100", "type": "HCPCS" } ], "description": "X-ray exam of jaw <4views", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70140", "type": "HCPCS" } ], "description": "X-ray exam of facial bones", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70160", "type": "HCPCS" } ], "description": "X-ray exam of nasal bones", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70190", "type": "HCPCS" } ], "description": "X-ray exam of eye sockets", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70210", "type": "HCPCS" } ], "description": "X-ray exam of sinuses", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70220", "type": "HCPCS" } ], "description": "X-ray exam of sinuses", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70240", "type": "HCPCS" } ], "description": "X-ray exam pituitary saddle", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70300", "type": "HCPCS" } ], "description": "X-ray exam of teeth", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70328", "type": "HCPCS" } ], "description": "X-ray exam of jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70330", "type": "HCPCS" } ], "description": "X-ray exam of jaw joints", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70350", "type": "HCPCS" } ], "description": "X-ray head for orthodontia", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70355", "type": "HCPCS" } ], "description": "Panoramic x-ray of jaws", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70360", "type": "HCPCS" } ], "description": "X-ray exam of neck", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70370", "type": "HCPCS" } ], "description": "Throat x-ray & fluoroscopy", "standard_charges": [ { "billing_class": "facility", 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"type": "HCPCS" } ], "description": "X-ray exam ribs uni 2 views", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71120", "type": "HCPCS" } ], "description": "X-ray exam breastbone 2/>vws", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71130", "type": "HCPCS" } ], "description": "X-ray strenoclavic jt 3/>vws", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72020", "type": "HCPCS" } ], "description": "X-ray exam of spine 1 view", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72040", "type": "HCPCS" } ], "description": "X-ray exam neck spine 2-3 vw", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72080", "type": "HCPCS" } ], "description": "X-ray exam thoracolmb 2/> vw", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72081", "type": "HCPCS" } ], "description": "X-ray exam entire spi 1 vw", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72220", "type": "HCPCS" } ], "description": "X-ray exam sacrum tailbone", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73000", "type": "HCPCS" } ], "description": "X-ray exam of collar bone", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73020", "type": "HCPCS" } ], "description": "X-ray exam of shoulder", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { 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], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73060", "type": "HCPCS" } ], "description": "X-ray exam of humerus", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73070", "type": "HCPCS" } ], "description": "X-ray exam of elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73080", "type": "HCPCS" } ], "description": "X-ray exam of elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73090", "type": "HCPCS" } ], "description": "X-ray exam of forearm", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73100", "type": "HCPCS" } ], "description": "X-ray exam of wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73110", "type": "HCPCS" } ], "description": "X-ray exam of wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73130", "type": "HCPCS" } ], "description": "X-ray exam of hand", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73140", "type": "HCPCS" } ], "description": "X-ray exam of finger(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73501", "type": "HCPCS" } ], "description": "X-ray exam hip uni 1 view", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73502", "type": "HCPCS" } ], "description": "X-ray exam hip uni 2-3 views", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73551", "type": "HCPCS" } ], "description": "X-ray exam of femur 1", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73552", "type": "HCPCS" } ], "description": "X-ray exam of femur 2/>", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73560", "type": "HCPCS" } ], "description": "X-ray exam of knee 1 or 2", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73562", "type": "HCPCS" } ], "description": "X-ray exam of knee 3", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73565", "type": "HCPCS" } ], "description": "X-ray exam of knees", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73590", "type": "HCPCS" } ], "description": "X-ray exam of lower leg", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73592", "type": "HCPCS" } ], "description": "X-ray exam of leg infant", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73600", "type": "HCPCS" } ], "description": "X-ray exam of ankle", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73610", "type": "HCPCS" } ], "description": "X-ray exam of ankle", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73620", "type": "HCPCS" } ], "description": "X-ray exam of foot", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73630", "type": "HCPCS" } ], "description": "X-ray exam of foot", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73650", "type": "HCPCS" } ], "description": "X-ray exam of heel", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73660", "type": "HCPCS" } ], "description": "X-ray exam of toe(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74018", "type": "HCPCS" } ], "description": "X-ray exam abdomen 1 view", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75571", "type": "HCPCS" } ], "description": "Ct hrt w/o dye w/ca test", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76010", "type": "HCPCS" } ], "description": "X-ray nose to rectum", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76016", "type": "HCPCS" } ], "description": "Mr safety deter phys/qhp", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76380", "type": "HCPCS" } ], "description": "CAT scan follow-up study", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76390", "type": "HCPCS" } ], "description": "Mr spectroscopy", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76496", "type": "HCPCS" } ], "description": "Fluoroscopic procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76497", "type": "HCPCS" } ], "description": "Ct procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76498", "type": "HCPCS" } ], "description": "Mri procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76499", "type": "HCPCS" } ], "description": "Radiographic procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76529", "type": "HCPCS" } ], "description": "Echo exam of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76642", "type": "HCPCS" } ], "description": "Ultrasound breast limited", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76885", "type": "HCPCS" } ], "description": "Us exam infant hips dynamic", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76886", "type": "HCPCS" } ], "description": "Us exam infant hips static", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76999", "type": "HCPCS" } ], "description": "Echo examination procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77071", "type": "HCPCS" } ], "description": "X-Ray Stress View", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77078", "type": "HCPCS" } ], "description": "Ct bone density axial", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77081", "type": "HCPCS" } ], "description": "Dxa bone density/peripheral", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77086", "type": "HCPCS" } ], "description": "Fracture assessment via dxa", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77090", "type": "HCPCS" } ], "description": "Tbs techl prep&transmis data", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77091", "type": "HCPCS" } ], "description": "Tbs techl calculation only", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0220", "type": "HCPCS" } ], "description": "Intraoral periapical first", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0240", "type": "HCPCS" } ], "description": "Intraoral occlusal film", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0250", "type": "HCPCS" } ], "description": "Extraoral 2d project image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0251", "type": "HCPCS" } ], "description": "Extraoral posterior image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0270", "type": "HCPCS" } ], "description": "Dental bitewing single image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0272", "type": "HCPCS" } ], "description": "Dental bitewings two images", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0321", "type": "HCPCS" } ], "description": "Other tmj images by report", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0340", "type": "HCPCS" } ], "description": "2d cephalometric image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0350", "type": "HCPCS" } ], "description": "Oral/facial photo images", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0371", "type": "HCPCS" } ], "description": "Sialoendoscopy capt & interp", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0393", "type": "HCPCS" } ], "description": "Trtmnt simulation 3d image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0394", "type": "HCPCS" } ], "description": "Digital sub 2 or more images", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0395", "type": "HCPCS" } ], "description": "Fusion 2 or more 3d images", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0701", "type": "HCPCS" } ], "description": "Fracture of lower extremity M >=61.50", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0702", "type": "HCPCS" } ], "description": "Fracture of lower extremity M >=52.50 and M <61.50", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0703", "type": "HCPCS" } ], "description": "Fracture of lower extremity M >=41.50 and M <52.50", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0705", "type": "HCPCS" } ], "description": "Extra oral post radio image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0706", "type": "HCPCS" } ], "description": "Intraoral occlus radio image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0707", "type": "HCPCS" } ], "description": "Intraoral periap radio image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0708", "type": "HCPCS" } ], "description": "Intraoral bite radio image", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0709", "type": "HCPCS" } ], "description": "Intraoral cmplt radio images", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0183", "type": "HCPCS" } ], "description": "Software meas of cardiac vol", "standard_charges": [ { "billing_class": "facility", "maximum": 83.91, "minimum": 83.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0348T", "type": "HCPCS" } ], "description": "RSA spine exam", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0349T", "type": "HCPCS" } ], "description": "RSA upper extr exam", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0633T", "type": "HCPCS" } ], "description": "Ct breast w/3d uni c-", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0857T", "type": "HCPCS" } ], "description": "Opto-acoustic img breast uni", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0946T", "type": "HCPCS" } ], "description": "Ortho impl mvmt alys pair ct", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70110", "type": "HCPCS" } ], "description": "X-ray exam of jaw 4/> views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70120", "type": "HCPCS" } ], "description": "X-ray exam of mastoids", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70130", "type": "HCPCS" } ], "description": "X-ray exam of mastoids", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70150", "type": "HCPCS" } ], "description": "X-ray exam of facial bones", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70200", "type": "HCPCS" } ], "description": "X-ray exam of eye sockets", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70250", "type": "HCPCS" } ], "description": "X-ray exam of skull", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70260", "type": "HCPCS" } ], "description": "X-ray exam of skull", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70450", "type": "HCPCS" } ], "description": "Ct head/brain w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70480", "type": "HCPCS" } ], "description": "Ct orbit/ear/fossa w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70486", "type": "HCPCS" } ], "description": "Ct maxillofacial w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70490", "type": "HCPCS" } ], "description": "Ct soft tissue neck w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71048", "type": "HCPCS" } ], "description": "X-ray exam chest 4+ views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71101", "type": "HCPCS" } ], "description": "X-ray exam unilat ribs/chest", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71110", "type": "HCPCS" } ], "description": "X-ray exam ribs bil 3 views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": 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"billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72050", "type": "HCPCS" } ], "description": "X-ray exam neck spine 4/5vws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72052", "type": "HCPCS" } ], "description": "X-ray exam neck spine 6/>vws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72070", "type": "HCPCS" } ], "description": "X-ray exam thorac spine 2vws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72072", "type": "HCPCS" } ], "description": "X-ray exam thorac spine 3vws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72074", "type": "HCPCS" } ], "description": "X-ray exam thorac spine4/>vw", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72082", "type": "HCPCS" } ], "description": "X-ray exam entire spi 2/3 vw", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72083", "type": "HCPCS" } ], "description": "X-ray exam entire spi 4/5 vw", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72084", "type": "HCPCS" } ], "description": "X-ray exam entire spi 6/> vw", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72100", "type": "HCPCS" } ], "description": "X-ray exam l-s spine 2/3 vws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72110", "type": "HCPCS" } ], "description": "X-ray exam l-2 spine 4/>vws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72114", "type": "HCPCS" } ], "description": "X-ray exam l-s spine bending", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { 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"maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72131", "type": "HCPCS" } ], "description": "Ct lumbar spine w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72170", "type": "HCPCS" } ], "description": "X-ray exam of pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72190", "type": "HCPCS" } ], "description": "X-ray exam of pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72192", "type": "HCPCS" } ], "description": "Ct pelvis w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72200", "type": "HCPCS" } ], "description": "X-ray exam si joints", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72202", "type": "HCPCS" } ], "description": "X-ray exam si joints 3/> vws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73010", "type": "HCPCS" } ], "description": "X-ray exam of shoulder blade", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73092", "type": "HCPCS" } ], "description": "X-ray exam of arm infant", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73120", "type": "HCPCS" } ], "description": "X-ray exam of hand", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73200", "type": "HCPCS" } ], "description": "Ct upper extremity w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73503", "type": "HCPCS" } ], "description": "X-ray exam hip uni 4/> views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73521", "type": "HCPCS" } ], "description": "X-ray exam hips bi 2 views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73522", "type": "HCPCS" } ], "description": "X-ray exam hips bi 3-4 views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73523", "type": "HCPCS" } ], "description": "X-ray exam hips bi 5/> views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73564", "type": "HCPCS" } ], "description": "X-ray exam knee 4 or more", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73700", "type": "HCPCS" } ], "description": "Ct lower extremity w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74019", "type": "HCPCS" } ], "description": "X-ray exam abdomen 2 views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74021", "type": "HCPCS" } ], "description": "X-ray exam abdomen 3+ views", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74022", "type": "HCPCS" } ], "description": "X-ray exam series abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74150", "type": "HCPCS" } ], "description": "Ct abdomen w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74261", "type": "HCPCS" } ], "description": "Ct colonography dx", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74445", "type": "HCPCS" } ], "description": "X-ray exam of penis", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75809", "type": "HCPCS" } ], "description": "Nonvascular shunt x-ray", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76100", "type": "HCPCS" } ], "description": "X-ray exam of body section", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76120", "type": "HCPCS" } ], "description": "Cine/video x-rays", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76506", "type": "HCPCS" } ], "description": "Echo exam of head", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76511", "type": "HCPCS" } ], "description": "Ophth us quant a only", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76512", "type": "HCPCS" } ], "description": "Ophth us b w/non-quant a", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76513", "type": "HCPCS" } ], "description": "Echo exam of eye water bath", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76516", "type": "HCPCS" } ], "description": "Echo exam of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76519", "type": "HCPCS" } ], "description": "Echo exam of eye", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76536", "type": "HCPCS" } ], "description": "Us exam of head and neck", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76604", "type": "HCPCS" } ], "description": "Us exam chest", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76641", "type": "HCPCS" } ], "description": "Ultrasound breast complete", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76700", "type": "HCPCS" } ], "description": "Us exam abdom complete", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76705", "type": "HCPCS" } ], "description": "Echo exam of abdomen", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76706", "type": "HCPCS" } ], "description": "Us abdl aorta screen aaa", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76770", "type": "HCPCS" } ], "description": "Us exam abdo back wall comp", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76775", "type": "HCPCS" } ], "description": "Us exam abdo back wall lim", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76776", "type": "HCPCS" } ], "description": "Us exam k transpl w/doppler", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76800", "type": "HCPCS" } ], "description": "Us exam spinal canal", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76801", "type": "HCPCS" } ], "description": "Ob us < 14 wks single fetus", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76805", "type": "HCPCS" } ], "description": "Ob us >/= 14 wks sngl fetus", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76813", "type": "HCPCS" } ], "description": "Ob us nuchal meas 1 gest", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76815", "type": "HCPCS" } ], "description": "Ob us limited fetus(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76816", "type": "HCPCS" } ], "description": "Ob us follow-up per fetus", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76817", "type": "HCPCS" } ], "description": "Transvaginal us obstetric", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76818", "type": "HCPCS" } ], "description": "Fetal biophys profile w/nst", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76819", "type": "HCPCS" } ], "description": "Fetal biophys profil w/o nst", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76820", "type": "HCPCS" } ], "description": "Umbilical artery echo", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76821", "type": "HCPCS" } ], "description": "Middle cerebral artery echo", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76827", "type": "HCPCS" } ], "description": "Echo exam of fetal heart", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76828", "type": "HCPCS" } ], "description": "Echo exam of fetal heart", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76830", "type": "HCPCS" } ], "description": "Transvaginal us non-ob", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76856", "type": "HCPCS" } ], "description": "Us exam pelvic complete", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76857", "type": "HCPCS" } ], "description": "Us exam pelvic limited", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76870", "type": "HCPCS" } ], "description": "Us exam scrotum", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76872", "type": "HCPCS" } ], "description": "Us transrectal", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76873", "type": "HCPCS" } ], "description": "Echograp trans r pros study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76881", "type": "HCPCS" } ], "description": "Us xtr non-vasc complete", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76882", "type": "HCPCS" } ], "description": "Us xtr non-vasc lmtd", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76883", "type": "HCPCS" } ], "description": "Us nrv&acc strux 1xtr compre", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76977", "type": "HCPCS" } ], "description": "Us bone density measure", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76981", "type": "HCPCS" } ], "description": "Use parenchyma", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76982", "type": "HCPCS" } ], "description": "Use 1st target lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77072", "type": "HCPCS" } ], "description": "X-Rays for Bone Age", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77073", "type": "HCPCS" } ], "description": "X-rays bone length studies", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77074", "type": "HCPCS" } ], "description": "X-rays bone survey limited", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77075", "type": "HCPCS" } ], "description": "X-rays bone survey complete", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77076", "type": "HCPCS" } ], "description": "X-rays bone survey infant", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77077", "type": "HCPCS" } ], "description": "Joint survey single view", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77080", "type": "HCPCS" } ], "description": "Dxa bone density axial", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77085", "type": "HCPCS" } ], "description": "Dxa bone density study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93882", "type": "HCPCS" } ], "description": "Extracranial uni/ltd study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93888", "type": "HCPCS" } ], "description": "Intracranial limited study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93892", "type": "HCPCS" } ], "description": "Tcd emboli detect w/o inj", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93893", "type": "HCPCS" } ], "description": "Tcd emboli detect w/inj", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93926", "type": "HCPCS" } ], "description": "Lower extremity study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93931", "type": "HCPCS" } ], "description": "Upper extremity study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93971", "type": "HCPCS" } ], "description": "Extremity study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93976", "type": "HCPCS" } ], "description": "Vascular study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93979", "type": "HCPCS" } ], "description": "Vascular study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93980", "type": "HCPCS" } ], "description": "Penile vascular study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93981", "type": "HCPCS" } ], "description": "Penile vascular study", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93986", "type": "HCPCS" } ], "description": "Dup-scan 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"standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0382", "type": "HCPCS" } ], "description": "Cone beam ct capt maxilla", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0383", "type": "HCPCS" } ], "description": "Cone beam ct both jaws", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0384", "type": "HCPCS" } ], "description": "Cone beam ct capture TMJ", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0385", "type": "HCPCS" } ], "description": "Max MRI image capture", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0386", "type": "HCPCS" } ], "description": "Max ultrasound image capture", "standard_charges": [ { "billing_class": "facility", "maximum": 100.81, "minimum": 100.81, "payers_information": [ { 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"standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0609T", "type": "HCPCS" } ], "description": "Mrs disc pain acquisj data", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0611T", "type": "HCPCS" } ], "description": "Mrs disc pain alg alys data", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0636T", "type": "HCPCS" } ], "description": "Ct breast w/3d bi c-", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0743T", "type": "HCPCS" } ], "description": "B1 str & fx rsk vrt fx assmt", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0865T", "type": "HCPCS" } ], "description": "Quan mri alys brn w/o dx mri", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0866T", "type": "HCPCS" } ], "description": "Quan mri alys brn w/dx mri", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0944T", "type": "HCPCS" } ], "description": "3d cntr simula trgt lvr les", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0992T", "type": "HCPCS" } ], "description": "N-invas assmt car rsk w/o ct", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0993T", "type": "HCPCS" } ], "description": "N-invas assmt car rsk w/ct", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70170", "type": "HCPCS" } ], "description": "X-ray exam of tear duct", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70310", "type": "HCPCS" } ], "description": "X-ray exam of teeth", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70320", "type": "HCPCS" } ], "description": "Full mouth x-ray of teeth", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70332", "type": "HCPCS" } ], "description": "X-ray exam of jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70336", "type": "HCPCS" } ], "description": "Magnetic image jaw joint", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70371", "type": "HCPCS" } ], "description": "Speech evaluation complex", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70390", "type": "HCPCS" } ], "description": "X-ray exam of salivary duct", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70540", "type": "HCPCS" } ], "description": "Mri orbit/face/neck w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70544", "type": "HCPCS" } ], "description": "Mr Angiography Head W/O Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70547", "type": "HCPCS" } ], "description": "Mr Angiography Neck W/O Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70551", "type": "HCPCS" } ], "description": "Mri brain stem w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70554", "type": "HCPCS" } ], "description": "Fmri brain by tech", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70555", "type": "HCPCS" } ], "description": "Fmri brain by phys/psych", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71550", "type": "HCPCS" } ], "description": "Mri chest w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72141", "type": "HCPCS" } ], "description": "Mri neck spine w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72146", "type": "HCPCS" } ], "description": "Mri chest spine w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72148", "type": "HCPCS" } ], "description": "Mri lumbar spine w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72195", "type": "HCPCS" } ], "description": "Mri Pelvis W/O Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73218", "type": "HCPCS" } ], "description": "Mri Upper Extremity W/O Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73221", "type": "HCPCS" } ], "description": "Mri joint upr extrem w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73718", "type": "HCPCS" } ], "description": "Mri Lower Extremity W/O Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73721", "type": "HCPCS" } ], "description": "Mri jnt of lwr extre w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74176", "type": "HCPCS" } ], "description": "Ct abd & pelvis w/o contrast", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74181", "type": "HCPCS" } ], "description": "Mri abdomen w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74263", "type": "HCPCS" } ], "description": "Ct colonography screening", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74440", "type": "HCPCS" } ], "description": "X-ray male genital tract", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74450", "type": "HCPCS" } ], "description": "X-ray urethra/bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74455", "type": "HCPCS" } ], "description": "X-ray urethra/bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74712", "type": "HCPCS" } ], "description": "Mri fetal sngl/1st gestation", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74740", "type": "HCPCS" } ], "description": "X-ray female genital tract", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74775", "type": "HCPCS" } ], "description": "X-ray exam of perineum", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75557", "type": "HCPCS" } ], "description": "Cardiac mri for morph", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76000", "type": "HCPCS" } ], "description": "Fluoroscope examination", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76017", "type": "HCPCS" } ], "description": "Mr sfty med physics xm cstmz", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76391", "type": "HCPCS" } ], "description": "Mr elastography", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76811", "type": "HCPCS" } ], "description": "Ob us detailed sngl fetus", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76826", "type": "HCPCS" } ], "description": "Echo exam of fetal heart", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76831", "type": "HCPCS" } ], "description": "Echo exam uterus", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76975", "type": "HCPCS" } ], "description": "GI endoscopic ultrasound", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77046", "type": "HCPCS" } ], "description": "Mri breast c- unilateral", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77047", "type": "HCPCS" } ], "description": "Mri breast c- bilateral", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77053", "type": "HCPCS" } ], "description": "X-Ray of Mammary Duct", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77054", "type": "HCPCS" } ], "description": "X-ray of mammary ducts", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77084", "type": "HCPCS" } ], "description": "Magnetic image bone marrow", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93307", "type": "HCPCS" } ], "description": "Tte w/o doppler complete", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93308", "type": "HCPCS" } ], "description": "Tte f-up or lmtd", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93880", "type": "HCPCS" } ], "description": "Extracranial bilat study", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93886", "type": "HCPCS" } ], "description": "Intracranial complete study", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93925", "type": "HCPCS" } ], "description": "Lower extremity study", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93930", "type": "HCPCS" } ], "description": "Upper extremity study", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93970", "type": "HCPCS" } ], "description": "Extremity study", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93975", "type": "HCPCS" } ], "description": "Vascular study", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93978", "type": "HCPCS" } ], "description": "Vascular study", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93985", "type": "HCPCS" } ], "description": "Dup-scan hemo compl bi std", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8901", "type": "HCPCS" } ], "description": "Mra w/o cont, abd", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8910", "type": "HCPCS" } ], "description": "MRA w/o cont, chest", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8913", "type": "HCPCS" } ], "description": "Mra w/o cont, lwr ext", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8919", "type": "HCPCS" } ], "description": "MRA w/o cont, pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8932", "type": "HCPCS" } ], "description": "MRA, w/o dye, spinal canal", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8935", "type": "HCPCS" } ], "description": "MRA, w/o dye, upper extr", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0210", "type": "HCPCS" } ], "description": "Intraor complete film series", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0273", "type": "HCPCS" } ], "description": "Bitewings - three images", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0274", "type": "HCPCS" } ], "description": "Bitewings four images", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0277", "type": "HCPCS" } ], "description": "Vert bitewings 7 to 8 images", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0310", "type": "HCPCS" } ], "description": "Dental saliography", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0320", "type": "HCPCS" } ], "description": "Dental tmj arthrogram incl i", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0330", "type": "HCPCS" } ], "description": "Panoramic image", "standard_charges": [ { "billing_class": "facility", "maximum": 230.07, "minimum": 230.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70134", "type": "HCPCS" } ], "description": "X-ray exam of middle ear", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70557", "type": "HCPCS" } ], "description": "Mri brain w/o dye", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74190", "type": "HCPCS" } ], "description": "X-ray exam of peritoneum", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74470", "type": "HCPCS" } ], "description": "X-ray exam of kidney lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75559", "type": "HCPCS" } ], "description": "Cardiac mri w/stress img", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76080", "type": "HCPCS" } ], "description": "X-ray exam of fistula", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76098", "type": "HCPCS" } ], "description": "X-ray exam breast specimen", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76825", "type": "HCPCS" } ], "description": "Echo exam of fetal heart", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93303", "type": "HCPCS" } ], "description": "Echo transthoracic", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93304", "type": "HCPCS" } ], "description": "Echo transthoracic", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93306", "type": "HCPCS" } ], "description": "Tte w/doppler complete", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93312", "type": "HCPCS" } ], "description": "Echo transesophageal", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93313", "type": "HCPCS" } ], "description": "Echo transesophageal", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93315", "type": "HCPCS" } ], "description": "Echo transesophageal", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93316", "type": "HCPCS" } ], "description": "Echo transesophageal", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93318", "type": "HCPCS" } ], "description": "Echo Transesophageal Intraop", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93350", "type": "HCPCS" } ], "description": "Stress tte only", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93351", "type": "HCPCS" } ], "description": "Stress tte complete", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9762", "type": "HCPCS" } ], "description": "Cardiac MRI seg dys strain", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9763", "type": "HCPCS" } ], "description": "Cardiac MRI seg dys stress", "standard_charges": [ { "billing_class": "facility", "maximum": 526.87, "minimum": 526.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 526.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0634T", "type": "HCPCS" } ], "description": "Ct breast w/3d uni c+", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0635T", "type": "HCPCS" } ], "description": "Ct breast w/3d uni c-/c+", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70460", "type": "HCPCS" } ], "description": "Ct head/brain w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70470", "type": "HCPCS" } ], "description": "Ct head/brain w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70473", "type": "HCPCS" } ], "description": "Ct cere prfu aly c+wo ct/cta", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70481", "type": "HCPCS" } ], "description": "Ct orbit/ear/fossa w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70482", "type": "HCPCS" } ], "description": "Ct orbit/ear/fossa w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70487", "type": "HCPCS" } ], "description": "Ct maxillofacial w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70488", "type": "HCPCS" } ], "description": "Ct maxillofacial w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70491", "type": "HCPCS" } ], "description": "Ct soft tissue neck w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70492", "type": "HCPCS" } ], "description": "Ct sft tsue nck w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70496", "type": "HCPCS" } ], "description": "Ct angiography head", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70498", "type": "HCPCS" } ], "description": "Ct angiography neck", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70558", "type": "HCPCS" } ], "description": "Mri brain w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70559", "type": "HCPCS" } ], "description": "Mri brain w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71260", "type": "HCPCS" } ], "description": "Ct thorax w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71270", "type": "HCPCS" } ], "description": "Ct thorax w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71275", "type": "HCPCS" } ], "description": "Ct angiography chest", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72127", "type": "HCPCS" } ], "description": "Ct neck spine w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72129", "type": "HCPCS" } ], "description": "Ct chest spine w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72130", "type": "HCPCS" } ], "description": "Ct chest spine w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72133", "type": "HCPCS" } ], "description": "Ct lumbar spine w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72191", "type": "HCPCS" } ], "description": "Ct angiograph pelv w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72193", "type": "HCPCS" } ], "description": "Ct pelvis w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72194", "type": "HCPCS" } ], "description": "Ct pelvis w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73202", "type": "HCPCS" } ], "description": "Ct uppr extremity w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73206", "type": "HCPCS" } ], "description": "Ct angio upr extrm w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73701", "type": "HCPCS" } ], "description": "Ct lower extremity w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73702", "type": "HCPCS" } ], "description": "Ct lwr extremity w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73706", "type": "HCPCS" } ], "description": "Ct angio lwr extr w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74160", "type": "HCPCS" } ], "description": "Ct abdomen w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74170", "type": "HCPCS" } ], "description": "Ct abdomen w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74175", "type": "HCPCS" } ], "description": "Ct angio abdom w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74210", "type": "HCPCS" } ], "description": "Contrst x-ray exam of throat", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74220", "type": "HCPCS" } ], "description": "Contrast x-ray esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74221", "type": "HCPCS" } ], "description": "X-ray xm esophagus 2cntrst", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74230", "type": "HCPCS" } ], "description": "Cine/vid x-ray throat/esoph", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74240", "type": "HCPCS" } ], "description": "X-ray upper gi delay w/o kub", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74246", "type": "HCPCS" } ], "description": "Contrst x-ray uppr gi tract", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74250", "type": "HCPCS" } ], "description": "X-ray exam of small bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74251", "type": "HCPCS" } ], "description": "X-ray exam of small bowel", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74262", "type": "HCPCS" } ], "description": "Ct colonography dx w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74270", "type": "HCPCS" } ], "description": "Contrast x-ray exam of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74280", "type": "HCPCS" } ], "description": "Contrast x-ray exam of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74283", "type": "HCPCS" } ], "description": "Contrast x-ray exam of colon", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74290", "type": "HCPCS" } ], "description": "Contrast x-ray gallbladder", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74400", "type": "HCPCS" } ], "description": "Contrst x-ray urinary tract", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74410", "type": "HCPCS" } ], "description": "Contrst x-ray urinary tract", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74415", "type": "HCPCS" } ], "description": "Contrst x-ray urinary tract", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75635", "type": "HCPCS" } ], "description": "Ct Angio Abdominal Arteries", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8903", "type": "HCPCS" } ], "description": "Mri w/cont, breast, uni", "standard_charges": [ { "billing_class": "facility", "maximum": 169.13, "minimum": 169.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 169.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0637T", "type": "HCPCS" } ], "description": "Ct breast w/3d bi c+", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0638T", "type": "HCPCS" } ], "description": "Ct breast w/3d bi c-/c+", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70010", "type": "HCPCS" } ], "description": "Contrast x-ray of brain", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70471", "type": "HCPCS" } ], "description": "Cta h&n c+ w/noncontrast img", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70542", "type": "HCPCS" } ], "description": "Mri Orbit/Face/Neck W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70543", "type": "HCPCS" } ], "description": "Mri orbt/fac/nck w/o &w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70545", "type": "HCPCS" } ], "description": "Mr Angiography Head W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70546", "type": "HCPCS" } ], "description": "Mr angiograph head w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70548", "type": "HCPCS" } ], "description": "Mr Angiography Neck W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70549", "type": "HCPCS" } ], "description": "Mr angiograph neck w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70552", "type": "HCPCS" } ], "description": "Mri brain stem w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70553", "type": "HCPCS" } ], "description": "Mri brain stem w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71552", "type": "HCPCS" } ], "description": "Mri chest w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72126", "type": "HCPCS" } ], "description": "Ct neck spine w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72132", "type": "HCPCS" } ], "description": "Ct lumbar spine w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72142", "type": "HCPCS" } ], "description": "Mri neck spine w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72147", "type": "HCPCS" } ], "description": "Mri chest spine w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72149", "type": "HCPCS" } ], "description": "Mri lumbar spine w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72156", "type": "HCPCS" } ], "description": "Mri neck spine w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72157", "type": "HCPCS" } ], "description": "Mri chest spine w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72158", "type": "HCPCS" } ], "description": "Mri lumbar spine w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72196", "type": "HCPCS" } ], "description": "Mri pelvis w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72197", "type": "HCPCS" } ], "description": "Mri pelvis w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73040", "type": "HCPCS" } ], "description": "Contrast x-ray of shoulder", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73085", "type": "HCPCS" } ], "description": "Contrast x-ray of elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73115", "type": "HCPCS" } ], "description": "Contrast x-ray of wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73201", "type": "HCPCS" } ], "description": "Ct upper extremity w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73219", "type": "HCPCS" } ], "description": "Mri Upper Extremity W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73220", "type": "HCPCS" } ], "description": "Mri uppr extremity w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73223", "type": "HCPCS" } ], "description": "Mri joint upr extr w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73525", "type": "HCPCS" } ], "description": "Contrast x-ray of hip", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73580", "type": "HCPCS" } ], "description": "Contrast x-ray of knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73615", "type": "HCPCS" } ], "description": "Contrast x-ray of ankle", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73719", "type": "HCPCS" } ], "description": "Mri Lower Extremity W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73720", "type": "HCPCS" } ], "description": "Mri lwr extremity w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73723", "type": "HCPCS" } ], "description": "Mri joint lwr extr w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74174", "type": "HCPCS" } ], "description": "Ct angio abd&pelv w/o&w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74177", "type": "HCPCS" } ], "description": "Ct abd & pelv w/contrast", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74178", "type": "HCPCS" } ], "description": "Ct abd & pelv 1/> regns", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74182", "type": "HCPCS" } ], "description": "Mri Abdomen W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74183", "type": "HCPCS" } ], "description": "Mri abdomen w/o & w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74420", "type": "HCPCS" } ], "description": "Contrst x-ray urinary tract", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74425", "type": "HCPCS" } ], "description": "Contrst x-ray urinary tract", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "74430", "type": "HCPCS" } ], "description": "Contrast x-ray bladder", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75561", "type": "HCPCS" } ], "description": "Cardiac mri for morph w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75572", "type": "HCPCS" } ], "description": "Ct hrt w/3d image", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75573", "type": "HCPCS" } ], "description": "Ct hrt w/3d image congen", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75574", "type": "HCPCS" } ], "description": "Ct angio hrt w/3d image", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76978", "type": "HCPCS" } ], "description": "Us trgt dyn mbubb 1st les", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8900", "type": "HCPCS" } ], "description": "Mra w/cont, abd", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8902", "type": "HCPCS" } ], "description": "Mra w/o fol w/cont, abd", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8905", "type": "HCPCS" } ], "description": "Mri w/o fol w/cont, brst, un", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8906", "type": "HCPCS" } ], "description": "Mri w/cont, breast, bi", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8908", "type": "HCPCS" } ], "description": "Mri w/o fol w/cont, breast,", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8909", "type": "HCPCS" } ], "description": "MRA w/cont, chest", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8911", "type": "HCPCS" } ], "description": "MRA w/o fol w/cont, chest", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8912", "type": "HCPCS" } ], "description": "Mra w/cont, lwr ext", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8914", "type": "HCPCS" } ], "description": "Mra w/o fol w/cont, lwr ext", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8918", "type": "HCPCS" } ], "description": "MRA w/cont, pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8920", "type": "HCPCS" } ], "description": "Mra w/o fol w/cont, pelvis", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8924", "type": "HCPCS" } ], "description": "2d tte w or w/o fol w/con,fu", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8931", "type": "HCPCS" } ], "description": "MRA, w/dye, spinal canal", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8933", "type": "HCPCS" } ], "description": "MRA, w/o&w/dye, spinal canal", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8934", "type": "HCPCS" } ], "description": "MRA, w/dye, upper extremity", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8936", "type": "HCPCS" } ], "description": "MRA, w/o&w/dye, upper extr", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9733", "type": "HCPCS" } ], "description": "Non-ophthalmic FVA", "standard_charges": [ { "billing_class": "facility", "maximum": 336.39, "minimum": 336.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 336.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "70015", "type": "HCPCS" } ], "description": "Contrast x-ray of brain", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "71551", "type": "HCPCS" } ], "description": "Mri Chest W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72240", "type": "HCPCS" } ], "description": "Myelography neck spine", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72255", "type": "HCPCS" } ], "description": "Myelography thoracic spine", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72265", "type": "HCPCS" } ], "description": "Myelography l-s spine", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "72270", "type": "HCPCS" } ], "description": "Myelogphy 2/> spine regions", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73222", "type": "HCPCS" } ], "description": "Mri joint upr extrem w/dye", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "73722", "type": "HCPCS" } ], "description": "Mri Joint Of Lwr Extr W/Dye", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75563", "type": "HCPCS" } ], "description": "Card mri w/stress img & dye", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8921", "type": "HCPCS" } ], "description": "Tte w or w/o fol w/cont, com", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8922", "type": "HCPCS" } ], "description": "Tte w or w/o fol w/cont, f/u", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8923", "type": "HCPCS" } ], "description": "2d tte w or w/o fol w/con,co", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8925", "type": "HCPCS" } ], "description": "2d tee w or w/o fol w/con,in", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8926", "type": "HCPCS" } ], "description": "Tee w or w/o fol w/cont,cong", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8927", "type": "HCPCS" } ], "description": "TEE w or w/o fol w/cont, mon", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8928", "type": "HCPCS" } ], "description": "Tte w or w/o fol w/con,stres", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8929", "type": "HCPCS" } ], "description": "TTE w or wo fol wcon,Doppler", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8930", "type": "HCPCS" } ], "description": "TTE w or w/o contr, cont ECG", "standard_charges": [ { "billing_class": "facility", "maximum": 755.87, "minimum": 755.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 755.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78012", "type": "HCPCS" } ], "description": "Thyroid uptake measurement", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78013", "type": "HCPCS" } ], "description": "Thyroid imaging w/blood flow", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78014", "type": "HCPCS" } ], "description": "Thyroid imaging w/blood flow", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78015", "type": "HCPCS" } ], "description": "Thyroid met imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78016", "type": "HCPCS" } ], "description": "Thyroid met imaging/studies", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78070", "type": "HCPCS" } ], "description": "Parathyroid planar imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78071", "type": "HCPCS" } ], "description": "Parathyrd planar w/wo subtrj", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78099", "type": "HCPCS" } ], "description": "Endocrine nuclear procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78102", "type": "HCPCS" } ], "description": "Bone marrow imaging ltd", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78103", "type": "HCPCS" } ], "description": "Bone marrow imaging mult", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78104", "type": "HCPCS" } ], "description": "Bone marrow imaging body", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78120", "type": "HCPCS" } ], "description": "Red cell mass single", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78130", "type": "HCPCS" } ], "description": "Red cell survival study", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78140", "type": "HCPCS" } ], "description": "Red cell sequestration", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78185", "type": "HCPCS" } ], "description": "Spleen imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78191", "type": "HCPCS" } ], "description": "Platelet survival", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78199", "type": "HCPCS" } ], "description": "Blood/lymph nuclear exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78215", "type": "HCPCS" } ], "description": "Liver and spleen imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78216", "type": "HCPCS" } ], "description": "Liver & spleen image/flow", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78226", "type": "HCPCS" } ], "description": "Hepatobiliary system imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78230", "type": "HCPCS" } ], "description": "Salivary gland imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78231", "type": "HCPCS" } ], "description": "Serial salivary imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78232", "type": "HCPCS" } ], "description": "Salivary gland function exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78258", "type": "HCPCS" } ], "description": "Esophageal motility study", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78261", "type": "HCPCS" } ], "description": "Gastric mucosa imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78262", "type": "HCPCS" } ], "description": "Gastroesophageal reflux exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78264", "type": "HCPCS" } ], "description": "Gastric emptying imag study", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78265", "type": "HCPCS" } ], "description": "Gastric emptying imag study", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78278", "type": "HCPCS" } ], "description": "Acute GI blood loss imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78282", "type": "HCPCS" } ], "description": "GI protein loss exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78290", "type": "HCPCS" } ], "description": "Meckels divert exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78291", "type": "HCPCS" } ], "description": "Leveen/shunt patency exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78299", "type": "HCPCS" } ], "description": "GI nuclear procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78300", "type": "HCPCS" } ], "description": "Bone imaging limited area", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78305", "type": "HCPCS" } ], "description": "Bone imaging multiple areas", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78306", "type": "HCPCS" } ], "description": "Bone imaging whole body", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78315", "type": "HCPCS" } ], "description": "Bone imaging 3 phase", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78399", "type": "HCPCS" } ], "description": "Musculoskeletal nuclear exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78428", "type": "HCPCS" } ], "description": "Cardiac shunt imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78445", "type": "HCPCS" } ], "description": "Vascular flow imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78458", "type": "HCPCS" } ], "description": "Ven thrombosis images bilat", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78466", "type": "HCPCS" } ], "description": "Heart infarct image", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78472", "type": "HCPCS" } ], "description": "Gated heart planar single", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78473", "type": "HCPCS" } ], "description": "Gated heart multiple", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78494", "type": "HCPCS" } ], "description": "Heart image spect", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78499", "type": "HCPCS" } ], "description": "Cardiovascular nuclear exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78579", "type": "HCPCS" } ], "description": "Lung ventilation imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78580", "type": "HCPCS" } ], "description": "Lung perfusion imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78597", "type": "HCPCS" } ], "description": "Lung perfusion differential", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78599", "type": "HCPCS" } ], "description": "Respiratory nuclear exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78600", "type": "HCPCS" } ], "description": "Brain image < 4 views", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78601", "type": "HCPCS" } ], "description": "Brain image w/flow < 4 views", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78660", "type": "HCPCS" } ], "description": "Nuclear exam of tear flow", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78699", "type": "HCPCS" } ], "description": "Nervous system nuclear exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78700", "type": "HCPCS" } ], "description": "Kidney imaging morphol", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78701", "type": "HCPCS" } ], "description": "Kidney imaging with flow", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78725", "type": "HCPCS" } ], "description": "Kidney function study", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78740", "type": "HCPCS" } ], "description": "Ureteral reflux study", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78761", "type": "HCPCS" } ], "description": "Testicular imaging w/flow", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78799", "type": "HCPCS" } ], "description": "Genitourinary nuclear exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78800", "type": "HCPCS" } ], "description": "Tumor imaging limited area", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78801", "type": "HCPCS" } ], "description": "Tumor imaging mult areas", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78808", "type": "HCPCS" } ], "description": "Iv inj ra drug dx study", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78999", "type": "HCPCS" } ], "description": "Nuclear diagnostic exam", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0235", "type": "HCPCS" } ], "description": "PET not otherwise specified", "standard_charges": [ { "billing_class": "facility", "maximum": 385.47, "minimum": 385.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 385.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78018", "type": "HCPCS" } ], "description": "Thyroid met imaging body", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78072", "type": "HCPCS" } ], "description": "Parathyrd planar w/spect&ct", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78121", "type": "HCPCS" } ], "description": "Red cell mass multiple", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78122", "type": "HCPCS" } ], "description": "Blood volume", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78195", "type": "HCPCS" } ], "description": "Lymph system imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78201", "type": "HCPCS" } ], "description": "Liver imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78202", "type": "HCPCS" } ], "description": "Liver imaging with flow", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78227", "type": "HCPCS" } ], "description": "Hepatobil syst image w/drug", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78266", "type": "HCPCS" } ], "description": "Gastric emptying imag study", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78414", "type": "HCPCS" } ], "description": "Non-imaging heart function", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78457", "type": "HCPCS" } ], "description": "Venous thrombosis imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78468", "type": "HCPCS" } ], "description": "Heart infarct image (ef)", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78469", "type": "HCPCS" } ], "description": "Heart infarct image (3D)", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78481", "type": "HCPCS" } ], "description": "Heart first pass single", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78483", "type": "HCPCS" } ], "description": "Heart first pass multiple", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78582", "type": "HCPCS" } ], "description": "Lung ventilat&perfus imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78598", "type": "HCPCS" } ], "description": "Lung perf&ventilat diferentl", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78605", "type": "HCPCS" } ], "description": "Brain image 4+ views", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78606", "type": "HCPCS" } ], "description": "Brain image w/flow 4 + views", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78610", "type": "HCPCS" } ], "description": "Brain flow imaging only", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78630", "type": "HCPCS" } ], "description": "Cerebrospinal fluid scan", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78635", "type": "HCPCS" } ], "description": "CSF ventriculography", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78645", "type": "HCPCS" } ], "description": "CSF shunt evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78707", "type": "HCPCS" } ], "description": "K flow/funct image w/o drug", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78708", "type": "HCPCS" } ], "description": "K flow/funct image w/drug", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78709", "type": "HCPCS" } ], "description": "K flow/funct image multiple", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78802", "type": "HCPCS" } ], "description": "Tumor imaging whole body", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78803", "type": "HCPCS" } ], "description": "Tumor imaging (3D)", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78804", "type": "HCPCS" } ], "description": "Tumor imaging whole body", "standard_charges": [ { "billing_class": "facility", "maximum": 523.54, "minimum": 523.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 523.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0331T", "type": "HCPCS" } ], "description": "Heart symp image plnr", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0332T", "type": "HCPCS" } ], "description": "Heart symp image plnr spect", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78075", "type": "HCPCS" } ], "description": "Adrenal cortex & medulla img", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78110", "type": "HCPCS" } ], "description": "Plasma volume single", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78111", "type": "HCPCS" } ], "description": "Plasma volume multiple", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78451", "type": "HCPCS" } ], "description": "Ht muscle image spect sing", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78452", "type": "HCPCS" } ], "description": "Ht muscle image spect mult", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78453", "type": "HCPCS" } ], "description": "Ht muscle image planar sing", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78454", "type": "HCPCS" } ], "description": "Ht musc image planar mult", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78456", "type": "HCPCS" } ], "description": "Acute venous thrombus image", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78459", "type": "HCPCS" } ], "description": "Heart muscle imaging (PET)", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78650", "type": "HCPCS" } ], "description": "CSF leakage imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78811", "type": "HCPCS" } ], "description": "Pet image ltd area", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78830", "type": "HCPCS" } ], "description": "Rp loclzj tum spect w/ct 1", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78831", "type": "HCPCS" } ], "description": "Rp loclzj tum spect 2 areas", "standard_charges": [ { "billing_class": "facility", "maximum": 1248.33, "minimum": 1248.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1248.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78429", "type": "HCPCS" } ], "description": "Myocrd img pet 1 std w/ct", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78430", "type": "HCPCS" } ], "description": "Myocrd img pet rst/strs w/ct", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78491", "type": "HCPCS" } ], "description": "Heart image (pet) single", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78492", "type": "HCPCS" } ], "description": "Heart image (pet) multiple", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78608", "type": "HCPCS" } ], "description": "Brain imaging (PET)", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78812", "type": "HCPCS" } ], "description": "Pet image skull-thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78813", "type": "HCPCS" } ], "description": "Pet image full body", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78814", "type": "HCPCS" } ], "description": "Pet image w/ct lmtd", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78815", "type": "HCPCS" } ], "description": "Pet image w/ct skull-thigh", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78816", "type": "HCPCS" } ], "description": "Pet image w/ct full body", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78832", "type": "HCPCS" } ], "description": "Rp loclzj tum spect w/ct 2", "standard_charges": [ { "billing_class": "facility", "maximum": 1378.79, "minimum": 1378.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1378.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1025T", "type": "HCPCS" } ], "description": "Alt elec fld dos&dlv sim mdl", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77280", "type": "HCPCS" } ], "description": "Set radiation therapy field", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77299", "type": "HCPCS" } ], "description": "Radiation therapy planning", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77300", "type": "HCPCS" } ], "description": "Radiation therapy dose plan", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77331", "type": "HCPCS" } ], "description": "Special radiation dosimetry", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77332", "type": "HCPCS" } ], "description": "Radiation treatment aid(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77333", "type": "HCPCS" } ], "description": "Radiation treatment aid(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77336", "type": "HCPCS" } ], "description": "Radiation physics consult", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77370", "type": "HCPCS" } ], "description": "Radiation physics consult", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77399", "type": "HCPCS" } ], "description": "External radiation dosimetry", "standard_charges": [ { "billing_class": "facility", "maximum": 129.6, "minimum": 129.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77285", "type": "HCPCS" } ], "description": "Set radiation therapy field", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77290", "type": "HCPCS" } ], "description": "Set radiation therapy field", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77306", "type": "HCPCS" } ], "description": "Telethx isodose plan simple", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77307", "type": "HCPCS" } ], "description": "Telethx isodose plan cplx", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77316", "type": "HCPCS" } ], "description": "Brachytx isodose plan simple", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77317", "type": "HCPCS" } ], "description": "Brachytx isodose intermed", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77318", "type": "HCPCS" } ], "description": "Brachytx isodose complex", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77321", "type": "HCPCS" } ], "description": "Special teletx port plan", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77334", "type": "HCPCS" } ], "description": "Radiation treatment aid(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77338", "type": "HCPCS" } ], "description": "Design mlc device for imrt", "standard_charges": [ { "billing_class": "facility", "maximum": 361.03, "minimum": 361.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77295", "type": "HCPCS" } ], "description": "3-d radiotherapy plan", "standard_charges": [ { "billing_class": "facility", "maximum": 1334.61, "minimum": 1334.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1334.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77301", "type": "HCPCS" } ], "description": "Radiotherapy dose plan imrt", "standard_charges": [ { "billing_class": "facility", "maximum": 1334.61, "minimum": 1334.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1334.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77407", "type": "HCPCS" } ], "description": "Radiation treatment delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 371.9, "minimum": 371.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 371.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77600", "type": "HCPCS" } ], "description": "Hyperthermia treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 371.9, "minimum": 371.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 371.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77750", "type": "HCPCS" } ], "description": "Infuse radioactive materials", "standard_charges": [ { "billing_class": "facility", "maximum": 371.9, "minimum": 371.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 371.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77767", "type": "HCPCS" } ], "description": "Hdr rdncl skn surf brachytx", "standard_charges": [ { "billing_class": "facility", "maximum": 371.9, "minimum": 371.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 371.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77768", "type": "HCPCS" } ], "description": "Hdr rdncl skn surf brachytx", "standard_charges": [ { "billing_class": "facility", "maximum": 371.9, "minimum": 371.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 371.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77412", "type": "HCPCS" } ], "description": "Radiation treatment delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77423", "type": "HCPCS" } ], "description": "Neutron beam tx complex", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77470", "type": "HCPCS" } ], "description": "Special radiation treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77520", "type": "HCPCS" } ], "description": "Proton trmt simple w/o comp", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77610", "type": "HCPCS" } ], "description": "Hyperthermia treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77615", "type": "HCPCS" } ], "description": "Hyperthermia treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77620", "type": "HCPCS" } ], "description": "Hyperthermia treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77761", "type": "HCPCS" } ], "description": "Apply intrcav radiat simple", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77762", "type": "HCPCS" } ], "description": "Apply intrcav radiat interm", "standard_charges": [ { "billing_class": "facility", "maximum": 532.77, "minimum": 532.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 532.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0395T", "type": "HCPCS" } ], "description": "Hdr elctr ntrst/ntrcv brchtx", "standard_charges": [ { "billing_class": "facility", "maximum": 671.56, "minimum": 671.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77605", "type": "HCPCS" } ], "description": "Hyperthermia treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 671.56, "minimum": 671.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77763", "type": "HCPCS" } ], "description": "Apply intrcav radiat compl", "standard_charges": [ { "billing_class": "facility", "maximum": 671.56, "minimum": 671.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77770", "type": "HCPCS" } ], "description": "Hdr rdncl ntrstl/icav brchtx", "standard_charges": [ { "billing_class": "facility", "maximum": 671.56, "minimum": 671.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77771", "type": "HCPCS" } ], "description": "Hdr rdncl ntrstl/icav brchtx", "standard_charges": [ { "billing_class": "facility", "maximum": 671.56, "minimum": 671.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77772", "type": "HCPCS" } ], "description": "Hdr rdncl ntrstl/icav brchtx", "standard_charges": [ { "billing_class": "facility", "maximum": 671.56, "minimum": 671.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77778", "type": "HCPCS" } ], "description": "Apply interstit radiat compl", "standard_charges": [ { "billing_class": "facility", "maximum": 671.56, "minimum": 671.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 671.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77373", "type": "HCPCS" } ], "description": "SBRT Delivery", "standard_charges": [ { "billing_class": "facility", "maximum": 1724.08, "minimum": 1724.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1724.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77371", "type": "HCPCS" } ], "description": "Srs multisource", "standard_charges": [ { "billing_class": "facility", "maximum": 7101.77, "minimum": 7101.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7101.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77372", "type": "HCPCS" } ], "description": "Srs linear based", "standard_charges": [ { "billing_class": "facility", "maximum": 7101.77, "minimum": 7101.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7101.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77424", "type": "HCPCS" } ], "description": "Io rad tx delivery by x-ray", "standard_charges": [ { "billing_class": "facility", "maximum": 7101.77, "minimum": 7101.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7101.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77425", "type": "HCPCS" } ], "description": "Io rad tx deliver by elctrns", "standard_charges": [ { "billing_class": "facility", "maximum": 7101.77, "minimum": 7101.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7101.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79005", "type": "HCPCS" } ], "description": "Nuclear rx oral admin", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79101", "type": "HCPCS" } ], "description": "Nuclear rx iv admin", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79200", "type": "HCPCS" } ], "description": "Nuclear rx intracav admin", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79300", "type": "HCPCS" } ], "description": "Nuclr rx interstit colloid", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79403", "type": "HCPCS" } ], "description": "Hematopoietic nuclear tx", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79440", "type": "HCPCS" } ], "description": "Nuclear rx intra-articular", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79445", "type": "HCPCS" } ], "description": "Nuclear rx intra-arterial", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "79999", "type": "HCPCS" } ], "description": "Nuclear medicine therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 224.99, "minimum": 224.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 224.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95115", "type": "HCPCS" } ], "description": "Immunotherapy one injection", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95117", "type": "HCPCS" } ], "description": "Immunotherapy injections", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95144", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95145", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95146", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95165", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95170", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96366", "type": "HCPCS" } ], "description": "Ther/proph/diag iv inf addon", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96370", "type": "HCPCS" } ], "description": "Sc ther infusion addl hr", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96375", "type": "HCPCS" } ], "description": "Tx/pro/dx inj new drug addon", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96377", "type": "HCPCS" } ], "description": "Applicaton on-body injector", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96379", "type": "HCPCS" } ], "description": "Ther/prop/diag inj/inf proc", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96423", "type": "HCPCS" } ], "description": "Chemo ia infuse each addl hr", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96549", "type": "HCPCS" } ], "description": "Chemotherapy unspecified", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "description": "Admin influenza virus vac", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0009", "type": "HCPCS" } ], "description": "Admin pneumococcal vaccine", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0010", "type": "HCPCS" } ], "description": "Admin hepatitis b vaccine", "standard_charges": [ { "billing_class": "facility", "maximum": 45.15, "minimum": 45.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90471", "type": "HCPCS" } ], "description": "Immunization admin", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90473", "type": "HCPCS" } ], "description": "Immune admin oral/nasal", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95147", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95148", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95149", "type": "HCPCS" } ], "description": "Antigen therapy services", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96367", "type": "HCPCS" } ], "description": "Tx/proph/dg addl seq iv inf", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96371", "type": "HCPCS" } ], "description": "Sc ther infusion reset pump", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96372", "type": "HCPCS" } ], "description": "Ther/proph/diag inj sc/im", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96401", "type": "HCPCS" } ], "description": "Chemo anti-neopl sq/im", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96402", "type": "HCPCS" } ], "description": "Chemo hormon antineopl sq/im", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96405", "type": "HCPCS" } ], "description": "Chemo intralesional up to 7", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96411", "type": "HCPCS" } ], "description": "Chemo iv push addl drug", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96415", "type": "HCPCS" } ], "description": "Chemo iv infusion addl hr", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96417", "type": "HCPCS" } ], "description": "Chemo iv infus each addl seq", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0012", "type": "HCPCS" } ], "description": "Injection of hiv prep drug", "standard_charges": [ { "billing_class": "facility", "maximum": 69.42, "minimum": 69.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96365", "type": "HCPCS" } ], "description": "Ther/proph/diag iv inf init", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96369", "type": "HCPCS" } ], "description": "Sc ther infusion up to 1 hr", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96373", "type": "HCPCS" } ], "description": "Ther/proph/diag inj ia", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96374", "type": "HCPCS" } ], "description": "Ther/proph/diag inj iv push", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96406", "type": "HCPCS" } ], "description": "Chemo intralesional over 7", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96521", "type": "HCPCS" } ], "description": "Refill/maint portable pump", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96522", "type": "HCPCS" } ], "description": "Refill/maint pump/resvr syst", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8957", "type": "HCPCS" } ], "description": "Prolonged iv inf, req pump", "standard_charges": [ { "billing_class": "facility", "maximum": 205.09, "minimum": 205.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95990", "type": "HCPCS" } ], "description": "Spin/brain pump refil & main", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96409", "type": "HCPCS" } ], "description": "Chemo iv push sngl drug", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96413", "type": "HCPCS" } ], "description": "Chemo iv infusion 1 hr", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96416", "type": "HCPCS" } ], "description": "Chemo prolong infuse w/pump", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96420", "type": "HCPCS" } ], "description": "Chemo ia push tecnique", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96422", "type": "HCPCS" } ], "description": "Chemo ia infusion up to 1 hr", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96425", "type": "HCPCS" } ], "description": "Chemotherapy infusion method", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96440", "type": "HCPCS" } ], "description": "Chemotherapy intracavitary", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96446", "type": "HCPCS" } ], "description": "Chemotx admn prtl cavity", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96450", "type": "HCPCS" } ], "description": "Chemotherapy into cns", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96542", "type": "HCPCS" } ], "description": "Chemotherapy injection", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0498", "type": "HCPCS" } ], "description": "Chemo extend iv infus w/pump", "standard_charges": [ { "billing_class": "facility", "maximum": 318.49, "minimum": 318.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0212T", "type": "HCPCS" } ], "description": "Compre audiometry evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0464T", "type": "HCPCS" } ], "description": "Visual ep test for glaucoma", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0778T", "type": "HCPCS" } ], "description": "Smmg cncrnt appl imu snr", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0783T", "type": "HCPCS" } ], "description": "Tc auriculr neurostimulation", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0812T", "type": "HCPCS" } ], "description": "Rem mlt day uroflow dev sply", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51784", "type": "HCPCS" } ], "description": "Anal/urinary muscle study", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91200", "type": "HCPCS" } ], "description": "Liver elastography", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91299", "type": "HCPCS" } ], "description": "Gastroenterology procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92274", "type": "HCPCS" } ], "description": "Multifocal erg w/i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92517", "type": "HCPCS" } ], "description": "Vemp test i&r cervical", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92518", "type": "HCPCS" } ], "description": "Vemp test i&r ocular", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92537", "type": "HCPCS" } ], "description": "Caloric vstblr test w/rec", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92544", "type": "HCPCS" } ], "description": "Optokinetic nystagmus test", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92546", "type": "HCPCS" } ], "description": "Sinusoidal rotational test", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92553", "type": "HCPCS" } ], "description": "Audiometry air & bone", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92557", "type": "HCPCS" } ], "description": "Comprehensive hearing test", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92570", "type": "HCPCS" } ], "description": "Acoustic immitance testing", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92572", "type": "HCPCS" } ], "description": "Staggered spondaic word test", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92582", "type": "HCPCS" } ], "description": "Conditioning play audiometry", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92584", "type": "HCPCS" } ], "description": "Electrocochleography", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92601", "type": "HCPCS" } ], "description": "Cochlear implt f/up exam <7", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92602", "type": "HCPCS" } ], "description": "Reprogram cochlear implt 7/>", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92603", "type": "HCPCS" } ], "description": "Cochlear implt f/up exam 7/>", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92604", "type": "HCPCS" } ], "description": "Reprogram cochlear implt 7/>", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92620", "type": "HCPCS" } ], "description": "Auditory function 60 min", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92622", "type": "HCPCS" } ], "description": "Dx aly aud oi snd prcsr 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92625", "type": "HCPCS" } ], "description": "Tinnitus assessment", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92626", "type": "HCPCS" } ], "description": "Eval aud rehab status", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92640", "type": "HCPCS" } ], "description": "Aud brainstem implt programg", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93025", "type": "HCPCS" } ], "description": "Microvolt t-wave assess", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93145", "type": "HCPCS" } ], "description": "Interrog crtd sins bat ip wo", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93146", "type": "HCPCS" } ], "description": "Interrog crtd sins bat ip w/", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93702", "type": "HCPCS" } ], "description": "Bis xtracell fluid analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93740", "type": "HCPCS" } ], "description": "Temperature gradient studies", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93799", "type": "HCPCS" } ], "description": "Cardiovascular procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94011", "type": "HCPCS" } ], "description": "Spirometry up to 2 yrs old", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94150", "type": "HCPCS" } ], "description": "Vital capacity test", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94450", "type": "HCPCS" } ], "description": "Hypoxia response curve", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94680", "type": "HCPCS" } ], "description": "Exhaled air analysis o2", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94728", "type": "HCPCS" } ], "description": "Pulm funct test oscillometry", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94762", "type": "HCPCS" } ], "description": "Measure blood oxygen level", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94775", "type": "HCPCS" } ], "description": "Ped home apnea rec hk-up", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94776", "type": "HCPCS" } ], "description": "Ped home apnea rec downld", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94799", "type": "HCPCS" } ], "description": "Pulmonary service/procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95863", "type": "HCPCS" } ], "description": "Muscle test 3 limbs", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95864", "type": "HCPCS" } ], "description": "Muscle test 4 limbs", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95866", "type": "HCPCS" } ], "description": "Muscle test hemidiaphragm", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95875", "type": "HCPCS" } ], "description": "Limb exercise test", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95921", "type": "HCPCS" } ], "description": "Autonomic nrv parasym inervj", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95937", "type": "HCPCS" } ], "description": "Neuromuscular junction test", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95999", "type": "HCPCS" } ], "description": "Neurological procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96112", "type": "HCPCS" } ], "description": "Devel tst phys/qhp 1st hr", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C8001", "type": "HCPCS" } ], "description": "3d anat seg imaging preop", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0566", "type": "HCPCS" } ], "description": "3d bn img algor drvd fr mri", "standard_charges": [ { "billing_class": "facility", "maximum": 124.07, "minimum": 124.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0509T", "type": "HCPCS" } ], "description": "Pattern erg w/i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0598T", "type": "HCPCS" } ], "description": "Ncntc r-t fluor wnd img 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0712T", "type": "HCPCS" } ], "description": "N-nvs artl plaq alys quan", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0766T", "type": "HCPCS" } ], "description": "Tc mag stimj pn 1st tx 1nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0807T", "type": "HCPCS" } ], "description": "Pulm tiss vntj alys prev ct", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0808T", "type": "HCPCS" } ], "description": "Pulm tiss vntj alys w/ct", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51741", "type": "HCPCS" } ], "description": "Electro-uroflowmetry first", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76936", "type": "HCPCS" } ], "description": "Echo guide for artery repair", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90867", "type": "HCPCS" } ], "description": "Tcranial magn stim tx plan", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90868", "type": "HCPCS" } ], "description": "Tcranial magn stim tx deli", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90869", "type": "HCPCS" } ], "description": "Tcran magn stim redetemine", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91037", "type": "HCPCS" } ], "description": "Esoph imped function test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91065", "type": "HCPCS" } ], "description": "Breath hydrogen/methane test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91117", "type": "HCPCS" } ], "description": "Colon motility 6 hr study", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91124", "type": "HCPCS" } ], "description": "Rct snsatn tone&cmplianc std", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91132", "type": "HCPCS" } ], "description": "Electrogastrography", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92137", "type": "HCPCS" } ], "description": "Cptrz oph img pst sg rta oct", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92235", "type": "HCPCS" } ], "description": "Fluorescein angrph uni/bi", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92240", "type": "HCPCS" } ], "description": "Icg angiography uni/bi", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92242", "type": "HCPCS" } ], "description": "Fluorescein icg angiography", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92273", "type": "HCPCS" } ], "description": "Full field erg w/i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92512", "type": "HCPCS" } ], "description": "Nasal function studies", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92516", "type": "HCPCS" } ], "description": "Facial nerve function test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92519", "type": "HCPCS" } ], "description": "Vemp tst i&r cervical&ocular", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92538", "type": "HCPCS" } ], "description": "Caloric vstblr test w/rec", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92540", "type": "HCPCS" } ], "description": "Basic vestibular evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92545", "type": "HCPCS" } ], "description": "Oscillating tracking test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92550", "type": "HCPCS" } ], "description": "Tympanometry & reflex thresh", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92562", "type": "HCPCS" } ], "description": "Loudness balance test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92579", "type": "HCPCS" } ], "description": "Visual audiometry (vra)", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92587", "type": "HCPCS" } ], "description": "Evoked auditory test limited", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92651", "type": "HCPCS" } ], "description": "Aep hearing status deter i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92652", "type": "HCPCS" } ], "description": "Aep thrshld est mlt freq i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92653", "type": "HCPCS" } ], "description": "Aep neurodiagnostic i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92950", "type": "HCPCS" } ], "description": "Heart/lung resuscitation cpr", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93017", "type": "HCPCS" } ], "description": "Cardiovascular stress test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93923", "type": "HCPCS" } ], "description": "Upr/lxtr art stdy 3+ lvls", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93924", "type": "HCPCS" } ], "description": "Lwr xtr vasc stdy bilat", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94010", "type": "HCPCS" } ], "description": "Breathing capacity test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94012", "type": "HCPCS" } ], "description": "Spirmtry w/brnchdil inf-2 yr", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94015", "type": "HCPCS" } ], "description": "Patient recorded spirometry", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94375", "type": "HCPCS" } ], "description": "Respiratory flow volume loop", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94727", "type": "HCPCS" } ], "description": "Pulm function test by gas", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95700", "type": "HCPCS" } ], "description": "Eeg cont rec w/vid eeg tech", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95705", "type": "HCPCS" } ], "description": "Eeg w/o vid 2-12 hr unmntr", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95706", "type": "HCPCS" } ], "description": "Eeg wo vid 2-12hr intmt mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95707", "type": "HCPCS" } ], "description": "Eeg w/o vid 2-12hr cont mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95711", "type": "HCPCS" } ], "description": "Veeg 2-12 hr unmonitored", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95800", "type": "HCPCS" } ], "description": "Slp stdy unattended", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95806", "type": "HCPCS" } ], "description": "Sleep study unatt&resp efft", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95812", "type": "HCPCS" } ], "description": "Eeg 41-60 minutes", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95813", "type": "HCPCS" } ], "description": "Eeg over 1 hour", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95816", "type": "HCPCS" } ], "description": "Eeg awake and drowsy", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95819", "type": "HCPCS" } ], "description": "Eeg awake and asleep", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95822", "type": "HCPCS" } ], "description": "Eeg coma or sleep only", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95857", "type": "HCPCS" } ], "description": "Cholinesterase challenge", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95867", "type": "HCPCS" } ], "description": "Muscle test cran nerv unilat", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95868", "type": "HCPCS" } ], "description": "Muscle test cran nerve bilat", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95869", "type": "HCPCS" } ], "description": "Muscle test thor paraspinal", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95872", "type": "HCPCS" } ], "description": "Muscle test one fiber", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95907", "type": "HCPCS" } ], "description": "Nvr cndj tst 1-2 studies", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95908", "type": "HCPCS" } ], "description": "Nrv cndj tst 3-4 studies", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95909", "type": "HCPCS" } ], "description": "Nrv cndj tst 5-6 studies", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95924", "type": "HCPCS" } ], "description": "Ans parasymp & symp w/tilt", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95925", "type": "HCPCS" } ], "description": "Somatosensory testing", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95926", "type": "HCPCS" } ], "description": "Somatosensory testing", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95927", "type": "HCPCS" } ], "description": "Somatosensory testing", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95930", "type": "HCPCS" } ], "description": "Visual evoked potential test", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96002", "type": "HCPCS" } ], "description": "Dynamic surface emg", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96116", "type": "HCPCS" } ], "description": "Neurobehavioral status exam", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96130", "type": "HCPCS" } ], "description": "Psycl tst eval phys/qhp 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0303", "type": "HCPCS" } ], "description": "Pre-op service LVRS 10-15dos", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0398", "type": "HCPCS" } ], "description": "Home sleep test/type 2 porta", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0399", "type": "HCPCS" } ], "description": "Home sleep test/type 3 porta", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0400", "type": "HCPCS" } ], "description": "Home sleep test/type 4 porta", "standard_charges": [ { "billing_class": "facility", "maximum": 208.2, "minimum": 208.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 208.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0541T", "type": "HCPCS" } ], "description": "Myocardial imaging mcg", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0779T", "type": "HCPCS" } ], "description": "Gi myoelectrical actv study", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0868T", "type": "HCPCS" } ], "description": "Hi-res gastric ep mapping", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76145", "type": "HCPCS" } ], "description": "Med physic dos eval rad exps", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91010", "type": "HCPCS" } ], "description": "Esophagus motility study", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91020", "type": "HCPCS" } ], "description": "Gastric motility studies", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91022", "type": "HCPCS" } ], "description": "Duodenal motility study", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91030", "type": "HCPCS" } ], "description": "Acid perfusion of esophagus", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91034", "type": "HCPCS" } ], "description": "Gastroesophageal reflux test", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91038", "type": "HCPCS" } ], "description": "Esoph imped funct test > 1hr", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91040", "type": "HCPCS" } ], "description": "Esoph balloon distension tst", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91125", "type": "HCPCS" } ], "description": "Anrct mano rct snsatn&balo", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92230", "type": "HCPCS" } ], "description": "Eye exam with photos", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92577", "type": "HCPCS" } ], "description": "Stenger test speech", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92588", "type": "HCPCS" } ], "description": "Evoked auditory tst complete", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93229", "type": "HCPCS" } ], "description": "Remote 30 day ecg tech supp", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93660", "type": "HCPCS" } ], "description": "Tilt table evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94013", "type": "HCPCS" } ], "description": "Meas lung vol thru 2 yrs", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94060", "type": "HCPCS" } ], "description": "Evaluation of wheezing", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94070", "type": "HCPCS" } ], "description": "Evaluation of wheezing", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94621", "type": "HCPCS" } ], "description": "Pulm stress test/complex", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94681", "type": "HCPCS" } ], "description": "Exhaled air analysis o2/co2", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94726", "type": "HCPCS" } ], "description": "Pulm funct tst plethysmograp", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94772", "type": "HCPCS" } ], "description": "Breath recording infant", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95070", "type": "HCPCS" } ], "description": "Bronchial allergy tests", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95076", "type": "HCPCS" } ], "description": "Ingest challenge ini 120 min", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95708", "type": "HCPCS" } ], "description": "Eeg wo vid ea 12-26hr unmntr", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95709", "type": "HCPCS" } ], "description": "Eeg w/o vid ea 12-26hr intmt", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95710", "type": "HCPCS" } ], "description": "Eeg w/o vid ea 12-26hr cont", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95712", "type": "HCPCS" } ], "description": "Veeg 2-12 hr intmt mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95713", "type": "HCPCS" } ], "description": "Veeg 2-12 hr cont mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95714", "type": "HCPCS" } ], "description": "Veeg ea 12-26 hr unmntr", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95715", "type": "HCPCS" } ], "description": "Veeg ea 12-26hr intmt mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95807", "type": "HCPCS" } ], "description": "Sleep study attended", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95824", "type": "HCPCS" } ], "description": "Eeg cerebral death only", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95910", "type": "HCPCS" } ], "description": "Nrv cndj test 7-8 studies", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95911", "type": "HCPCS" } ], "description": "Nrv cndj test 9-10 studies", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95912", "type": "HCPCS" } ], "description": "Nrv cndj test 11-12 studies", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95913", "type": "HCPCS" } ], "description": "Nrv cndj test 13/> studies", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95929", "type": "HCPCS" } ], "description": "C motor evoked lwr limbs", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95954", "type": "HCPCS" } ], "description": "EEG monitoring/giving drugs", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96000", "type": "HCPCS" } ], "description": "Motion analysis video/3d", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { 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"standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0304", "type": "HCPCS" } ], "description": "Pre-op service LVRS 1-9 dos", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0305", "type": "HCPCS" } ], "description": "Post op service LVRS min 6", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G2000", "type": "HCPCS" } ], "description": "Blinded conv. Tx MDD clin tr", "standard_charges": [ { "billing_class": "facility", "maximum": 359.81, "minimum": 359.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0897T", "type": "HCPCS" } ], "description": "N-invas augmnt arrhyt alys", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0898T", "type": "HCPCS" } ], "description": "N-invas prst8 cancer est map", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "75580", "type": "HCPCS" } ], "description": "N-invas est c ffr sw aly cta", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90870", "type": "HCPCS" } ], "description": "Electroconvulsive therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91035", "type": "HCPCS" } ], "description": "G-esoph reflx tst w/electrod", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95004", "type": "HCPCS" } ], "description": "Percut allergy skin tests", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95044", "type": "HCPCS" } ], "description": "Allergy patch tests", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95716", "type": "HCPCS" } ], "description": "Veeg ea 12-26hr cont mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95782", "type": "HCPCS" } ], "description": "Polysom <6 yrs 4/> paramtrs", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95783", "type": "HCPCS" } ], "description": "Polysom <6 yrs cpap/bilvl", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95805", "type": "HCPCS" } ], "description": "Multiple sleep latency test", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95808", "type": "HCPCS" } ], "description": "Polysom any age 1-3> param", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95810", "type": "HCPCS" } ], "description": "Polysom 6/> yrs 4/> param", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95811", "type": "HCPCS" } ], "description": "Polysom 6/>yrs cpap 4/> parm", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95928", "type": "HCPCS" } ], "description": "C motor evoked uppr limbs", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95938", "type": "HCPCS" } ], "description": "Somatosensory testing", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95939", "type": "HCPCS" } ], "description": "C motor evoked upr&lwr limbs", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95958", "type": "HCPCS" } ], "description": "EEG monitoring/function test", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95961", "type": "HCPCS" } ], "description": "Electrode stimulation brain", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95965", "type": "HCPCS" } ], "description": "Meg spontaneous", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95966", "type": "HCPCS" } ], "description": "Meg evoked single", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96001", "type": "HCPCS" } ], "description": "Motion test w/ft press meas", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C9793", "type": "HCPCS" } ], "description": "Pre-plan 3d model w/ccta", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0555", "type": "HCPCS" } ], "description": "Replacment pt electronic sys", "standard_charges": [ { "billing_class": "facility", "maximum": 828.02, "minimum": 828.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 828.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0358T", "type": "HCPCS" } ], "description": "BIA whole body", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0521T", "type": "HCPCS" } ], "description": "Interrog dev eval wcs ip", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0555T", "type": "HCPCS" } ], "description": "B1 str&fx rsk transmis data", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1002T", "type": "HCPCS" } ], "description": "Air displacmnt plethysmograp", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76014", "type": "HCPCS" } ], "description": "Mr sfty implt&/fb asmt stf 1", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76514", "type": "HCPCS" } ], "description": "Echo exam of eye thickness", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92499", "type": "HCPCS" } ], "description": "Eye service or procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92700", "type": "HCPCS" } ], "description": "Ent procedure/service", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93050", "type": "HCPCS" } ], "description": "Art pressure waveform analys", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93291", "type": "HCPCS" } ], "description": "Ilr device interrogate", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93998", "type": "HCPCS" } ], "description": "Noninvas vasc dx study proc", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95017", "type": "HCPCS" } ], "description": "Perq & icut allg test venoms", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95027", "type": "HCPCS" } ], "description": "Icut allergy titrate-airborn", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95199", "type": "HCPCS" } ], "description": "Allergy immunology services", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96146", "type": "HCPCS" } ], "description": "Psycl/nrpsyc tst auto result", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97810", "type": "HCPCS" } ], "description": "Acupunct w/o stimul 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97813", "type": "HCPCS" } ], "description": "Acupunct w/stimul 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99473", "type": "HCPCS" } ], "description": "Self-meas bp pt educaj/train", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0117", "type": "HCPCS" } ], "description": "Glaucoma scrn hgh risk direc", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0237", "type": "HCPCS" } ], "description": "Therapeutic procd strg endur", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0238", "type": "HCPCS" } ], "description": "Oth resp proc, indiv", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0404", "type": "HCPCS" } ], "description": "EKG tracing for initial prev", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0541", "type": "HCPCS" } ], "description": "No pt prsnt train initial 30", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0543", "type": "HCPCS" } ], "description": "Group train w/o patient", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G2011", "type": "HCPCS" } ], "description": "Alcohol/sub abuse assess", "standard_charges": [ { "billing_class": "facility", "maximum": 27.89, "minimum": 27.89, "payers_information": [ { 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36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0109T", "type": "HCPCS" } ], "description": "Heat Quant Sensory Test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0208T", "type": "HCPCS" } ], "description": "Audiometry air only", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0209T", "type": "HCPCS" } ], "description": "Audiometry air & bone", "standard_charges": 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schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0330T", "type": "HCPCS" } ], "description": "Tear film img uni/bi w/i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0379T", "type": "HCPCS" } ], "description": "Vis field assmnt tech suppt", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0485T", "type": "HCPCS" } ], "description": "Oct mid ear i&r unilateral", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0486T", "type": "HCPCS" } ], "description": "Oct mid ear i&r bilateral", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0640T", "type": "HCPCS" } ], "description": "Ncntc nr ifr spctrsc wnd", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77436", "type": "HCPCS" } ], "description": "Surf radj ther tx planning", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92228", "type": "HCPCS" } ], "description": "Remote retinal imaging mgmt", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92260", "type": "HCPCS" } ], "description": "Ophthalmoscopy/dynamometry", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92285", "type": "HCPCS" } ], "description": "Eye photography", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92317", "type": "HCPCS" } ], "description": "Rx corneoscleral cntact lens", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92354", "type": "HCPCS" } ], "description": "Fit spectacles single system", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92355", "type": "HCPCS" } ], "description": "Fit spectacles compound lens", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92563", "type": "HCPCS" } ], "description": "Tone decay hearing test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92567", "type": "HCPCS" } ], "description": "Tympanometry", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92568", "type": "HCPCS" } ], "description": "Acoustic refl threshold tst", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92571", "type": "HCPCS" } ], "description": "Filtered speech hearing test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92575", "type": "HCPCS" } ], "description": "Sensorineural acuity test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92576", "type": "HCPCS" } ], "description": "Synthetic sentence test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92596", "type": "HCPCS" } ], "description": "Ear protector evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93242", "type": "HCPCS" } ], "description": "Ext ecg>48hr<7d recording", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93246", "type": "HCPCS" } ], "description": "Ext ecg>7d<15d recording", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94780", "type": "HCPCS" } ], "description": "Car seat/bed test 60 min", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95012", "type": "HCPCS" } ], "description": "Exhaled Nitric Oxide Meas", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95018", "type": "HCPCS" } ], "description": "Perq&ic allg test drugs/biol", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95028", "type": "HCPCS" } ], "description": "Icut allergy test-delayed", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95065", "type": "HCPCS" } ], "description": "Nose allergy test", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96127", "type": "HCPCS" } ], "description": "Brief emotional/behav assmt", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96900", "type": "HCPCS" } ], "description": "Ultraviolet light therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97037", "type": "HCPCS" } ], "description": "Appl modality 1+lllt po pain", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0118", "type": "HCPCS" } ], "description": "Glaucoma scrn hgh risk direc", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0239", "type": "HCPCS" } ], "description": "Oth resp proc, group", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0293", "type": "HCPCS" } ], "description": "Non-cov surg proc,clin trial", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0294", "type": "HCPCS" } ], "description": "Non-cov proc, clinical trial", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0035", "type": "HCPCS" } ], "description": "Cardiokymography", "standard_charges": [ { "billing_class": "facility", "maximum": 36.01, "minimum": 36.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0108T", "type": "HCPCS" } ], "description": "Cool Quant Sensory Test", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0506T", "type": "HCPCS" } ], "description": "Mac pgmt opt dns meas hfp", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0507T", "type": "HCPCS" } ], "description": "Near ifr 2img mibmn glnd i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0658T", "type": "HCPCS" } ], "description": "Elec impd spectrsc 1+skn les", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0716T", "type": "HCPCS" } ], "description": "Car acous wavfrm rec cad rsk", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0731T", "type": "HCPCS" } ], "description": "Augmnt ai-based fcl phnt a/r", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0740T", "type": "HCPCS" } ], "description": "Rem auton alg nsln cal setup", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0794T", "type": "HCPCS" } ], "description": "Pt spec alg rx-onc tx option", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0904T", "type": "HCPCS" } ], "description": "Ecg alg 12 ld rdcd trcg only", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0911T", "type": "HCPCS" } ], "description": "Elec aly nstm sys vgs nrv wo", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1017T", "type": "HCPCS" } ], "description": "Elec aly npgs esoph sbsq w/o", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1020T", "type": "HCPCS" } ], "description": "Raman spectroscopy 1+skn les", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51792", "type": "HCPCS" } ], "description": "Urinary reflex study", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51798", "type": "HCPCS" } ], "description": "Us urine capacity measure", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76019", "type": "HCPCS" } ], "description": "Mr safety implt pos&/immoblj", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92025", "type": "HCPCS" } ], "description": "Corneal Topography", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92060", "type": "HCPCS" } ], "description": "Special eye evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92066", "type": "HCPCS" } ], "description": "Orthop traing supvj phys/qhp", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92081", "type": "HCPCS" } ], "description": "Visual field examination(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92082", "type": "HCPCS" } ], "description": "Visual field examination(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92132", "type": "HCPCS" } ], "description": "Cmptr ophth dx img ant segmt", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92133", "type": "HCPCS" } ], "description": "Cmptr ophth img optic nerve", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92134", "type": "HCPCS" } ], "description": "Cptr ophth dx img post segmt", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92145", "type": "HCPCS" } ], "description": "Corneal hysteresis deter", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92201", "type": "HCPCS" } ], "description": "Opscpy extnd rta draw uni/bi", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92202", "type": "HCPCS" } ], "description": "Opscpy extnd on/mac draw", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92227", "type": "HCPCS" } ], "description": "Remote dx retinal imaging", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92229", "type": "HCPCS" } ], "description": "Img rta detc/mntr ds poc aly", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92265", "type": "HCPCS" } ], "description": "Eye muscle evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92283", "type": "HCPCS" } ], "description": "Color vision examination", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92326", "type": "HCPCS" } ], "description": "Replacement of contact lens", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92352", "type": "HCPCS" } ], "description": "Fit aphakia spectcl monofocl", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92353", "type": "HCPCS" } ], "description": "Fit aphakia spectcl multifoc", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92358", "type": "HCPCS" } ], "description": "Aphakia prosth service temp", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92371", "type": "HCPCS" } ], "description": "Repair & adjust spectacles", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92555", "type": "HCPCS" } ], "description": "Speech threshold audiometry", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92556", "type": "HCPCS" } ], "description": "Speech audiometry complete", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92565", "type": "HCPCS" } ], "description": "Stenger test pure tone", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92583", "type": "HCPCS" } ], "description": "Select picture audiometry", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93005", "type": "HCPCS" } ], "description": "Electrocardiogram tracing", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93041", "type": "HCPCS" } ], "description": "Rhythm ecg tracing", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93226", "type": "HCPCS" } ], "description": "Ecg monit/reprt up to 48 hrs", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93278", "type": "HCPCS" } ], "description": "ECG/signal-averaged", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93668", "type": "HCPCS" } ], "description": "Peripheral Vascular Rehab", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94200", "type": "HCPCS" } ], "description": "Lung function test (MBC/MVV)", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94619", "type": "HCPCS" } ], "description": "Exercise tst brncspsm wo ecg", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94625", "type": "HCPCS" } ], "description": "Phy/qhp op pulm rhb w/o mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94626", "type": "HCPCS" } ], "description": "Phy/qhp op pulm rhb w/mntr", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94690", "type": "HCPCS" } ], "description": "Exhaled air analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95024", "type": "HCPCS" } ], "description": "Icut allergy test drug/bug", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95052", "type": "HCPCS" } ], "description": "Photo patch test", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95249", "type": "HCPCS" } ], "description": "Cont gluc mntr pt prov eqp", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95801", "type": "HCPCS" } ], "description": "Slp stdy unatnd w/anal", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95803", "type": "HCPCS" } ], "description": "Actigraphy testing", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95933", "type": "HCPCS" } ], "description": "Blink reflex test", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95981", "type": "HCPCS" } ], "description": "Io anal gast n-stim subsq", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96523", "type": "HCPCS" } ], "description": "Irrig drug delivery device", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96910", "type": "HCPCS" } ], "description": "Photochemotherapy with UV-B", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96912", "type": "HCPCS" } ], "description": "Photochemotherapy with UV-A", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0127", "type": "HCPCS" } ], "description": "Trim nail(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 56.88, "minimum": 56.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0110T", "type": "HCPCS" } ], "description": "Nos Quant Sensory Test", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0198T", "type": "HCPCS" } ], "description": "Ocular blood flow measure", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0559T", "type": "HCPCS" } ], "description": "Antmc mdl 3d print 1st cmpnt", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0561T", "type": "HCPCS" } ], "description": "Antmc guide 3d print 1st gd", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0615T", "type": "HCPCS" } ], "description": "Eye mvmt alys w/o calbrj i&r", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0764T", "type": "HCPCS" } ], "description": "Asstv alg ecg rsk asmt cncrt", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0765T", "type": "HCPCS" } ], "description": "Asstv alg ecg rsk asmt prev", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0893T", "type": "HCPCS" } ], "description": "N-invas assmt bld oxygnation", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0902T", "type": "HCPCS" } ], "description": "Qtc ntrvl augmnt alg aly ecg", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0962T", "type": "HCPCS" } ], "description": "Asstv alg alys acous&ecg rec", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1004T", "type": "HCPCS" } ], "description": "Elec alys s-scl eeg wo prgrm", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1010T", "type": "HCPCS" } ], "description": "Cptr oph alys monoc eye mvmt", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36591", "type": "HCPCS" } ], "description": "Draw blood off venous device", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "36592", "type": "HCPCS" } ], "description": "Collect blood from picc", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "51736", "type": "HCPCS" } ], "description": "Urine flow measurement", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76510", "type": "HCPCS" } ], "description": "Ophth us b & quant a", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "91133", "type": "HCPCS" } ], "description": "Electrogastrography W/Test", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92020", "type": "HCPCS" } ], "description": "Special eye evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92083", "type": "HCPCS" } ], "description": "Visual field examination(s)", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92136", "type": "HCPCS" } ], "description": "Ophthalmic biometry", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92250", "type": "HCPCS" } ], "description": "Eye exam with photos", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92270", "type": "HCPCS" } ], "description": "Electro-oculography", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92286", "type": "HCPCS" } ], "description": "Internal eye photography", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92287", "type": "HCPCS" } ], "description": "Internal eye photography", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92312", "type": "HCPCS" } ], "description": "Contact lens fitting", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92313", "type": "HCPCS" } ], "description": "Contact lens fitting", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92315", "type": "HCPCS" } ], "description": "Rx cntact lens aphakia 1 eye", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92316", "type": "HCPCS" } ], "description": "Rx cntact lens aphakia 2 eye", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92325", "type": "HCPCS" } ], "description": "Modification of contact lens", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92520", "type": "HCPCS" } ], "description": "Laryngeal function studies", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92541", "type": "HCPCS" } ], "description": "Spontaneous nystagmus test", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92542", "type": "HCPCS" } ], "description": "Positional nystagmus test", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92548", "type": "HCPCS" } ], "description": "Posturography", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92549", "type": "HCPCS" } ], "description": "Cdp-sot 6 cond w/i&r mct&adt", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92552", "type": "HCPCS" } ], "description": "Pure tone audiometry air", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93225", "type": "HCPCS" } ], "description": "Ecg monit/reprt up to 48 hrs", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93243", "type": "HCPCS" } ], "description": "Ext ecg>48hr<7d scan a/r", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93247", "type": "HCPCS" } ], "description": "Ext ecg>7d<15d scan a/r", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93701", "type": "HCPCS" } ], "description": "Bioimpedance cv analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93786", "type": "HCPCS" } ], "description": "Ambulatory BP recording", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93788", "type": "HCPCS" } ], "description": "Ambulatory BP analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93922", "type": "HCPCS" } ], "description": "Upr/l xtremity art 2 levels", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94452", "type": "HCPCS" } ], "description": "Hast w/report", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94453", "type": "HCPCS" } ], "description": "Hast w/oxygen titrate", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94617", "type": "HCPCS" } ], "description": "Exercise tst brncspsm", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94618", "type": "HCPCS" } ], "description": "Pulmonary stress testing", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94644", "type": "HCPCS" } ], "description": "Cbt 1st hour", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94667", "type": "HCPCS" } ], "description": "Chest wall manipulation", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94668", "type": "HCPCS" } ], "description": "Chest wall manipulation", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95056", "type": "HCPCS" } ], "description": "Photosensitivity tests", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95060", "type": "HCPCS" } ], "description": "Eye allergy tests", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95860", "type": "HCPCS" } ], "description": "Muscle test one limb", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95861", "type": "HCPCS" } ], "description": "Muscle test 2 limbs", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95865", "type": "HCPCS" } ], "description": "Muscle test larynx", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95870", "type": "HCPCS" } ], "description": "Muscle test nonparaspinal", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95919", "type": "HCPCS" } ], "description": "Quan puplmtry phy/qhp uni/bi", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95922", "type": "HCPCS" } ], "description": "Autonomic nrv adrenrg inervj", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95923", "type": "HCPCS" } ], "description": "Autonomic nrv syst funj test", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95970", "type": "HCPCS" } ], "description": "Analyze neurostim no prog", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96136", "type": "HCPCS" } ], "description": "Psycl/nrpsyc tst phy/qhp 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99195", "type": "HCPCS" } ], "description": "Phlebotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0166", "type": "HCPCS" } ], "description": "Extrnl counterpulse, per tx", "standard_charges": [ { "billing_class": "facility", "maximum": 128.29, "minimum": 128.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0881T", "type": "HCPCS" } ], "description": "Cryotherapy oral cavity", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92284", "type": "HCPCS" } ], "description": "Dark adaptation eye exam", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92311", "type": "HCPCS" } ], "description": "Contact lens fitting", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93024", "type": "HCPCS" } ], "description": "Cardiac drug stress test", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94014", "type": "HCPCS" } ], "description": "Patient recorded spirometry", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95180", "type": "HCPCS" } ], "description": "Rapid desensitization", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95905", "type": "HCPCS" } ], "description": "Motor &/ sens nrve cndj test", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96138", "type": "HCPCS" } ], "description": "Psycl/nrpsyc tech 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 430.74, "minimum": 430.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0473T", "type": "HCPCS" } ], "description": "Reprgrmg io rta eltrd ra", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0589T", "type": "HCPCS" } ], "description": "Elec alys smpl prgrmg iins", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0590T", "type": "HCPCS" } ], "description": "Elec alys cplx prgrmg iins", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0788T", "type": "HCPCS" } ], "description": "Elec aly smp iins sp/sac nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0789T", "type": "HCPCS" } ], "description": "Elec aly cpx iins sp/sac nrv", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0912T", "type": "HCPCS" } ], "description": "Elec alys nstim sys vgs smpl", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "1005T", "type": "HCPCS" } ], "description": "Elec alys s-scl eeg prgr 1st", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "76018", "type": "HCPCS" } ], "description": "Mr safety implant elec prepj", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93150", "type": "HCPCS" } ], "description": "Therapy activation ipnss", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93151", "type": "HCPCS" } ], "description": "Interrog&prgrmg ipnss", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93153", "type": "HCPCS" } ], "description": "Interrog w/o prgrmg ipnss", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93271", "type": "HCPCS" } ], "description": "Ecg/monitoring and analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93750", "type": "HCPCS" } ], "description": "Interrogation vad in person", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95971", "type": "HCPCS" } ], "description": "Analyze neurostim simple", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95972", "type": "HCPCS" } ], "description": "Analyze neurostim complex", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95977", "type": "HCPCS" } ], "description": "Alys cplx cn npgt prgrmg", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95983", "type": "HCPCS" } ], "description": "Alys brn npgt prgrmg 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 91.67, "minimum": 91.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93797", "type": "HCPCS" } ], "description": "Cardiac rehab", "standard_charges": [ { "billing_class": "facility", "maximum": 124.3, "minimum": 124.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "93798", "type": "HCPCS" } ], "description": "Cardiac rehab/monitor", "standard_charges": [ { "billing_class": "facility", "maximum": 124.3, "minimum": 124.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0422", "type": "HCPCS" } ], "description": "Intens cardiac rehab w/exerc", "standard_charges": [ { "billing_class": "facility", "maximum": 124.3, "minimum": 124.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0423", "type": "HCPCS" } ], "description": "Intens cardiac rehab no exer", "standard_charges": [ { "billing_class": "facility", "maximum": 124.3, "minimum": 124.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92953", "type": "HCPCS" } ], "description": "Temporary external pacing", "standard_charges": [ { "billing_class": "facility", "maximum": 637.3, "minimum": 637.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 637.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92960", "type": "HCPCS" } ], "description": "Cardioversion electric ext", "standard_charges": [ { "billing_class": "facility", "maximum": 637.3, "minimum": 637.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 637.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92961", "type": "HCPCS" } ], "description": "Cardioversion electric int", "standard_charges": [ { "billing_class": "facility", "maximum": 637.3, "minimum": 637.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 637.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99465", "type": "HCPCS" } ], "description": "Nb resuscitation", "standard_charges": [ { "billing_class": "facility", "maximum": 637.3, "minimum": 637.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 637.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94610", "type": "HCPCS" } ], "description": "Surfactant Admin Thru Tube", "standard_charges": [ { "billing_class": "facility", "maximum": 211.14, "minimum": 211.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 211.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94640", "type": "HCPCS" } ], "description": "Airway inhalation treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 211.14, "minimum": 211.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 211.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94642", "type": "HCPCS" } ], "description": "Aerosol inhalation treatment", "standard_charges": [ { "billing_class": "facility", "maximum": 211.14, "minimum": 211.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 211.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94660", "type": "HCPCS" } ], "description": "Pos airway pressure cpap", "standard_charges": [ { "billing_class": "facility", "maximum": 211.14, "minimum": 211.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 211.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94664", "type": "HCPCS" } ], "description": "Evaluate pt use of inhaler", "standard_charges": [ { "billing_class": "facility", "maximum": 211.14, "minimum": 211.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 211.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94669", "type": "HCPCS" } ], "description": "Mechanical chest wall oscill", "standard_charges": [ { "billing_class": "facility", "maximum": 211.14, "minimum": 211.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 211.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94002", "type": "HCPCS" } ], "description": "Vent mgmt inpat init day", "standard_charges": [ { "billing_class": "facility", "maximum": 595.69, "minimum": 595.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 595.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94003", "type": "HCPCS" } ], "description": "Vent mgmt inpat subq day", "standard_charges": [ { "billing_class": "facility", "maximum": 595.69, "minimum": 595.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 595.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90853", "type": "HCPCS" } ], "description": "Group psychotherapy", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90880", "type": "HCPCS" } ], "description": "Hypnotherapy", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96156", "type": "HCPCS" } ], "description": "Hlth bhv assmt/reassessment", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97151", "type": "HCPCS" } ], "description": "Bhv id assmt by phys/qhp", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97152", "type": "HCPCS" } ], "description": "Bhv id suprt assmt by 1 tech", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97153", "type": "HCPCS" } ], "description": "Adaptive behavior tx by tech", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99426", "type": "HCPCS" } ], "description": "Prin care mgmt staff 1st 30", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99483", "type": "HCPCS" } ], "description": "Assmt & care pln pt cog imp", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99490", "type": "HCPCS" } ], "description": "Chron care mgmt srvc 20 min", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99492", "type": "HCPCS" } ], "description": "1st psyc collab care mgmt", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99493", "type": "HCPCS" } ], "description": "Sbsq psyc collab care mgmt", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99497", "type": "HCPCS" } ], "description": "Advncd care plan 30 min", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "C7901", "type": "HCPCS" } ], "description": "Hopd mntl hlt, 30-60 min", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0019", "type": "HCPCS" } ], "description": "Comm hlth intg svs sdoh 60mn", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0023", "type": "HCPCS" } ], "description": "Pin service 60m per month", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0101", "type": "HCPCS" } ], "description": "CA screen;pelvic/breast exam", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0140", "type": "HCPCS" } ], "description": "Nav srv peer sup 60 min pr m", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0296", "type": "HCPCS" } ], "description": "Visit to determ ldct elig", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0443", "type": "HCPCS" } ], "description": "Brief alcohol misuse counsel", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0445", "type": "HCPCS" } ], "description": "High inten beh couns STD 30m", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0447", "type": "HCPCS" } ], "description": "Behavior counsel obesity 15m", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0451", "type": "HCPCS" } ], "description": "Devlopment test interpt&rep", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0538", "type": "HCPCS" } ], "description": "Ascvd rsk mng clin stf pr mo", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0544", "type": "HCPCS" } ], "description": "Post d/c phone follow up", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0558", "type": "HCPCS" } ], "description": "Adv prim care mgmt lvl 3", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0568", "type": "HCPCS" } ], "description": "Int psych care mng, 1 cal mo", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0569", "type": "HCPCS" } ], "description": "Subs psych care mng, subs mo", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G2214", "type": "HCPCS" } ], "description": "Init/sub psych care m 1st 30", "standard_charges": [ { "billing_class": "facility", "maximum": 97.95, "minimum": 97.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90791", "type": "HCPCS" } ], "description": "Psych diagnostic evaluation", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90792", "type": "HCPCS" } ], "description": "Psych diag eval w/med srvcs", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90832", "type": "HCPCS" } ], "description": "Psytx w pt 30 minutes", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90834", "type": "HCPCS" } ], "description": "Psytx w pt 45 minutes", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90837", "type": "HCPCS" } ], "description": "Psytx w pt 60 minutes", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90839", "type": "HCPCS" } ], "description": "Psytx crisis initial 60 min", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90845", "type": "HCPCS" } ], "description": "Psychoanalysis", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90846", "type": "HCPCS" } ], "description": "Family psytx w/o pt 50 min", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90847", "type": "HCPCS" } ], "description": "Family psytx w/pt 50 min", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90849", "type": "HCPCS" } ], "description": "Multiple family group psytx", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90865", "type": "HCPCS" } ], "description": "Narcosynthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96158", "type": "HCPCS" } ], "description": "Hlth bhv ivntj indiv 1st 30", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97155", "type": "HCPCS" } ], "description": "Adapt behavior tx phys/qhp", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "99487", "type": "HCPCS" } ], "description": "Cmplx chron care w/o pt vsit", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0397", "type": "HCPCS" } ], "description": "Alcohol/subs interv >30 min", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G2086", "type": "HCPCS" } ], "description": "Off base opioid tx 70min", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G2087", "type": "HCPCS" } ], "description": "Off\u00a0base opioid tx, 60 m", "standard_charges": [ { "billing_class": "facility", "maximum": 171.15, "minimum": 171.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0460", "type": "HCPCS" } ], "description": "Pulp vitality test", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D0600", "type": "HCPCS" } ], "description": "Non-ionizing diag proc", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1510", "type": "HCPCS" } ], "description": "Space maintainer fxd unilat", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1516", "type": "HCPCS" } ], "description": "Fixed bilat space maint, max", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1517", "type": "HCPCS" } ], "description": "Fixed bilat space maint, man", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1520", "type": "HCPCS" } ], "description": "Remove unilat space maintain", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1526", "type": "HCPCS" } ], "description": "Remove bilat space main, max", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1527", "type": "HCPCS" } ], "description": "Remove bilat space main, man", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1551", "type": "HCPCS" } ], "description": "Recement space maint - max", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1552", "type": "HCPCS" } ], "description": "Recement space maint - man", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1553", "type": "HCPCS" } ], "description": "Recement unilat space maint", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D1575", "type": "HCPCS" } ], "description": "Dist space maint, fixed unil", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2140", "type": "HCPCS" } ], "description": "Amalgam one surface permanen", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2150", "type": "HCPCS" } ], "description": "Amalgam two surfaces permane", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2160", "type": "HCPCS" } ], "description": "Amalgam three surfaces perma", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2161", "type": "HCPCS" } ], "description": "Amalgam 4 or > surfaces perm", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2330", "type": "HCPCS" } ], "description": "Resin one surface-anterior", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2331", "type": "HCPCS" } ], "description": "Resin two surfaces-anterior", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2332", "type": "HCPCS" } ], "description": "Resin three surfaces-anterio", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2335", "type": "HCPCS" } ], "description": "Resin 4/> surf or w incis an", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2390", "type": "HCPCS" } ], "description": "Ant resin-based cmpst crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2391", "type": "HCPCS" } ], "description": "Post 1 srfc resinbased cmpst", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2392", "type": "HCPCS" } ], "description": "Post 2 srfc resinbased cmpst", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2393", "type": "HCPCS" } ], "description": "Post 3 srfc resinbased cmpst", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2394", "type": "HCPCS" } ], "description": "Post >=4srfc resinbase cmpst", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2410", "type": "HCPCS" } ], "description": "Dental gold foil one surface", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2420", "type": "HCPCS" } ], "description": "Dental gold foil two surface", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2430", "type": "HCPCS" } ], "description": "Dental gold foil three surfa", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2510", "type": "HCPCS" } ], "description": "Dental inlay metalic 1 surf", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2520", "type": "HCPCS" } ], "description": "Dental inlay metallic 2 surf", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2530", "type": "HCPCS" } ], "description": "Dental inlay metl 3/more sur", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2542", "type": "HCPCS" } ], "description": "Dental onlay metallic 2 surf", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2543", "type": "HCPCS" } ], "description": "Dental onlay metallic 3 surf", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2544", "type": "HCPCS" } ], "description": "Dental onlay metl 4/more sur", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2610", "type": "HCPCS" } ], "description": "Inlay porcelain/ceramic 1 su", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2620", "type": "HCPCS" } ], "description": "Inlay porcelain/ceramic 2 su", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2630", "type": "HCPCS" } ], "description": "Dental onlay porc 3/more sur", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2642", "type": "HCPCS" } ], "description": "Dental onlay porcelin 2 surf", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2643", "type": "HCPCS" } ], "description": "Dental onlay porcelin 3 surf", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2644", "type": "HCPCS" } ], "description": "Dental onlay porc 4/more sur", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2650", "type": "HCPCS" } ], "description": "Inlay composite/resin one su", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2651", "type": "HCPCS" } ], "description": "Inlay composite/resin two su", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2652", "type": "HCPCS" } ], "description": "Dental inlay resin 3/mre sur", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2662", "type": "HCPCS" } ], "description": "Dental onlay resin 2 surface", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2663", "type": "HCPCS" } ], "description": "Dental onlay resin 3 surface", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2664", "type": "HCPCS" } ], "description": "Dental onlay resin 4/mre sur", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2710", "type": "HCPCS" } ], "description": "Crown resin-based indirect", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2712", "type": "HCPCS" } ], "description": "Crown 3/4 resin-based compos", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2720", "type": "HCPCS" } ], "description": "Crown resin w/ high noble me", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2721", "type": "HCPCS" } ], "description": "Crown resin w/ base metal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2722", "type": "HCPCS" } ], "description": "Crown resin w/ noble metal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2740", "type": "HCPCS" } ], "description": "Crown porcelain/ceramic subs", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2750", "type": "HCPCS" } ], "description": "Crown porcelain w/ h noble m", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2751", "type": "HCPCS" } ], "description": "Crown porcelain fused base m", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2752", "type": "HCPCS" } ], "description": "Crown porcelain w/ noble met", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2753", "type": "HCPCS" } ], "description": "Crown porc fused to titanium", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2780", "type": "HCPCS" } ], "description": "Crown 3/4 cast hi noble met", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2781", "type": "HCPCS" } ], "description": "Crown 3/4 cast base metal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2782", "type": "HCPCS" } ], "description": "Crown 3/4 cast noble metal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2783", "type": "HCPCS" } ], "description": "Crown 3/4 porcelain/ceramic", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2790", "type": "HCPCS" } ], "description": "Crown full cast high noble m", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2791", "type": "HCPCS" } ], "description": "Crown full cast base metal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2792", "type": "HCPCS" } ], "description": "Crown full cast noble metal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2794", "type": "HCPCS" } ], "description": "Crown-titanium", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2799", "type": "HCPCS" } ], "description": "Provisional crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2910", "type": "HCPCS" } ], "description": "Recement inlay onlay or part", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2915", "type": "HCPCS" } ], "description": "Recement cast or prefab post", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2920", "type": "HCPCS" } ], "description": "Re-cement or re-bond crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2921", "type": "HCPCS" } ], "description": "Reattach tooth fragment", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2928", "type": "HCPCS" } ], "description": "Prefab porc/cer crown perm", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2929", "type": "HCPCS" } ], "description": "Prefab porc/ceram crown pri", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2930", "type": "HCPCS" } ], "description": "Prefab stnlss steel crwn pri", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2931", "type": "HCPCS" } ], "description": "Prefab stnlss steel crown pe", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2932", "type": "HCPCS" } ], "description": "Prefabricated resin crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2933", "type": "HCPCS" } ], "description": "Prefab stainless steel crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2934", "type": "HCPCS" } ], "description": "Prefab steel crown primary", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2940", "type": "HCPCS" } ], "description": "Protective restoration", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2949", "type": "HCPCS" } ], "description": "Restorative foundation", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2950", "type": "HCPCS" } ], "description": "Core build-up incl any pins", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2951", "type": "HCPCS" } ], "description": "Tooth pin retention", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2952", "type": "HCPCS" } ], "description": "Post and core cast + crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2954", "type": "HCPCS" } ], "description": "Prefab post/core + crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2957", "type": "HCPCS" } ], "description": "Each addtnl prefab post", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2960", "type": "HCPCS" } ], "description": "Laminate labial veneer", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2961", "type": "HCPCS" } ], "description": "Lab labial veneer resin", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2962", "type": "HCPCS" } ], "description": "Lab labial veneer porcelain", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2971", "type": "HCPCS" } ], "description": "Add proc construct new crown", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2975", "type": "HCPCS" } ], "description": "Coping", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2980", "type": "HCPCS" } ], "description": "Crown repair", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2981", "type": "HCPCS" } ], "description": "Inlay repair", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2982", "type": "HCPCS" } ], "description": "Onlay repair", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2983", "type": "HCPCS" } ], "description": "Veneer repair", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2990", "type": "HCPCS" } ], "description": "Resin infiltration of lesion", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D2999", "type": "HCPCS" } ], "description": "Dental unspec restorative pr", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3110", "type": "HCPCS" } ], "description": "Pulp cap direct", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3120", "type": "HCPCS" } ], "description": "Pulp cap indirect", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3220", "type": "HCPCS" } ], "description": "Therapeutic pulpotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3221", "type": "HCPCS" } ], "description": "Gross pulpal debridement", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3222", "type": "HCPCS" } ], "description": "Part pulp for apexogenesis", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3230", "type": "HCPCS" } ], "description": "Pulpal therapy anterior prim", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3240", "type": "HCPCS" } ], "description": "Pulpal therapy posterior pri", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3310", "type": "HCPCS" } ], "description": "End thxpy, anterior tooth", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3320", "type": "HCPCS" } ], "description": "End thxpy, bicuspid tooth", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3330", "type": "HCPCS" } ], "description": "End thxpy, molar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3331", "type": "HCPCS" } ], "description": "Non-surg tx root canal obs", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3332", "type": "HCPCS" } ], "description": "Incomplete endodontic tx", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3333", "type": "HCPCS" } ], "description": "Internal root repair", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3346", "type": "HCPCS" } ], "description": "Retreat root canal anterior", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3347", "type": "HCPCS" } ], "description": "Retreat root canal bicuspid", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3348", "type": "HCPCS" } ], "description": "Retreat root canal molar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3351", "type": "HCPCS" } ], "description": "Apexification/recalc initial", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3352", "type": "HCPCS" } ], "description": "Apexification/recalc interim", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3353", "type": "HCPCS" } ], "description": "Apexification/recalc final", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3355", "type": "HCPCS" } ], "description": "Pulpal regeneration initial", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3356", "type": "HCPCS" } ], "description": "Pulpal regeneration interim", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3357", "type": "HCPCS" } ], "description": "Pulpal regeneration complete", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3410", "type": "HCPCS" } ], "description": "Apicoectomy - anterior", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3421", "type": "HCPCS" } ], "description": "Root surgery bicuspid", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3425", "type": "HCPCS" } ], "description": "Root surgery molar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3428", "type": "HCPCS" } ], "description": "Bone graft peri per tooth", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3430", "type": "HCPCS" } ], "description": "Retrograde filling", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3431", "type": "HCPCS" } ], "description": "Biological materials", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3432", "type": "HCPCS" } ], "description": "Guided tissue regeneration", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3450", "type": "HCPCS" } ], "description": "Root amputation", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3460", "type": "HCPCS" } ], "description": "Endodontic endosseous implan", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3470", "type": "HCPCS" } ], "description": "Intentional replantation", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3471", "type": "HCPCS" } ], "description": "Surg rep root res anterior", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3472", "type": "HCPCS" } ], "description": "Surg rep root res premolar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3473", "type": "HCPCS" } ], "description": "Surg rep root res molar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3501", "type": "HCPCS" } ], "description": "Surg exp root surf anterior", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3502", "type": "HCPCS" } ], "description": "Surg exp root surf premolar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3503", "type": "HCPCS" } ], "description": "Surg exp root surf molar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3910", "type": "HCPCS" } ], "description": "Isolation- tooth w rubb dam", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3911", "type": "HCPCS" } ], "description": "Intraorifice barrier", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3920", "type": "HCPCS" } ], "description": "Tooth splitting", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3921", "type": "HCPCS" } ], "description": "D?cor or submerg erupt tooth", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3950", "type": "HCPCS" } ], "description": "Canal prep/fitting of dowel", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D3999", "type": "HCPCS" } ], "description": "Endodontic procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4249", "type": "HCPCS" } ], "description": "Crown lengthen hard tissue", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4263", "type": "HCPCS" } ], "description": "Bone replce graft first site", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4265", "type": "HCPCS" } ], "description": "Bio mtrls to aid soft/os reg", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4268", "type": "HCPCS" } ], "description": "Surgical revision procedure", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4274", "type": "HCPCS" } ], "description": "Mesial/distal wedge proc", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4322", "type": "HCPCS" } ], "description": "Splint intra-coronal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4323", "type": "HCPCS" } ], "description": "Splint extra-coronal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4341", "type": "HCPCS" } ], "description": "Periodontal scaling & root", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4342", "type": "HCPCS" } ], "description": "Periodontal scaling 1-3teeth", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4346", "type": "HCPCS" } ], "description": "Scaling gingiv inflammation", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4355", "type": "HCPCS" } ], "description": "Full mouth debridement", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4381", "type": "HCPCS" } ], "description": "Localized delivery antimicro", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4910", "type": "HCPCS" } ], "description": "Periodontal maint procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D4920", "type": "HCPCS" } ], "description": "Unscheduled dressing change", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D5911", "type": "HCPCS" } ], "description": "Facial moulage sectional", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D5912", "type": "HCPCS" } ], "description": "Facial moulage complete", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D5983", "type": "HCPCS" } ], "description": "Radiation applicator", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D5984", "type": "HCPCS" } ], "description": "Radiation shield", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D5985", "type": "HCPCS" } ], "description": "Radiation cone locator", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D5987", "type": "HCPCS" } ], "description": "Commissure splint", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D5988", "type": "HCPCS" } ], "description": "Surgical splint", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D6920", "type": "HCPCS" } ], "description": "Dental connector bar", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7111", "type": "HCPCS" } ], "description": "Extraction coronal remnants", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7140", "type": "HCPCS" } ], "description": "Extraction erupted tooth/exr", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7220", "type": "HCPCS" } ], "description": "Impact tooth remov soft tiss", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7230", "type": "HCPCS" } ], "description": "Impact tooth remov part bony", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7240", "type": "HCPCS" } ], "description": "Impact tooth remov comp bony", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7241", "type": "HCPCS" } ], "description": "Impact tooth rem bony w/comp", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7250", "type": "HCPCS" } ], "description": "Tooth root removal", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7260", "type": "HCPCS" } ], "description": "Oral antral fistula closure", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7261", "type": "HCPCS" } ], "description": "Primary closure sinus perf", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7270", "type": "HCPCS" } ], "description": "Tooth reimplantation", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7272", "type": "HCPCS" } ], "description": "Tooth transplantation", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7280", "type": "HCPCS" } ], "description": "Exposure of unerupted tooth", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7291", "type": "HCPCS" } ], "description": "Transseptal fiberotomy", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7460", "type": "HCPCS" } ], "description": "Rem nonodonto cyst to 1.25cm", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7461", "type": "HCPCS" } ], "description": "Rem nonodonto cyst > 1.25 cm", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7472", "type": "HCPCS" } ], "description": "Removal of torus palatinus", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7473", "type": "HCPCS" } ], "description": "Remove torus mandibularis", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7530", "type": "HCPCS" } ], "description": "Removal fb skin/areolar tiss", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7540", "type": "HCPCS" } ], "description": "Removal of fb reaction", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7550", "type": "HCPCS" } ], "description": "Removal of sloughed off bone", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7922", "type": "HCPCS" } ], "description": "Place intra-socket bio dress", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D7940", "type": "HCPCS" } ], "description": "Reshaping bone orthognathic", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D9930", "type": "HCPCS" } ], "description": "Treatment of complications", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D9944", "type": "HCPCS" } ], "description": "Occ guard, hard, full arch", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D9945", "type": "HCPCS" } ], "description": "Occ guard, soft, full arch", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D9946", "type": "HCPCS" } ], "description": "Occ guard, hard, part arch", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D9950", "type": "HCPCS" } ], "description": "Occlusion analysis", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D9951", "type": "HCPCS" } ], "description": "Limited occlusal adjustment", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "D9952", "type": "HCPCS" } ], "description": "Complete occlusal adjustment", "standard_charges": [ { "billing_class": "facility", "maximum": 623.36, "minimum": 623.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 623.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9022", "type": "HCPCS" } ], "description": "Washed red blood cells unit", "standard_charges": [ { "billing_class": "facility", "maximum": 368.58, "minimum": 368.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 368.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9040", "type": "HCPCS" } ], "description": "RBC leukoreduced irradiated", "standard_charges": [ { "billing_class": "facility", "maximum": 265.41, "minimum": 265.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 265.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9037", "type": "HCPCS" } ], "description": "Plate pheres leukoredu irrad", "standard_charges": [ { "billing_class": "facility", "maximum": 680.61, "minimum": 680.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "P9073", "type": "HCPCS" } ], "description": "Platelets, pathogen reduced", "standard_charges": [ { "billing_class": "facility", "maximum": 607.43, "minimum": 607.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 607.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0002M", "type": "HCPCS" } ], "description": "Liver dis 10 assays w/ash", "standard_charges": [ { "billing_class": "facility", "maximum": 503.4, "minimum": 503.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 503.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0003M", "type": "HCPCS" } ], "description": "Liver dis 10 assays w/nash", "standard_charges": [ { "billing_class": "facility", "maximum": 503.4, "minimum": 503.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 503.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0004M", "type": "HCPCS" } ], "description": "Scoliosis dna alys", "standard_charges": [ { "billing_class": "facility", "maximum": 79.0, "minimum": 79.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0006M", "type": "HCPCS" } ], "description": "Onc hep gene risk classifier", "standard_charges": [ { "billing_class": "facility", "maximum": 150.0, "minimum": 150.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0007M", "type": "HCPCS" } ], "description": "Onc gastro 51 gene nomogram", "standard_charges": [ { "billing_class": "facility", "maximum": 375.0, "minimum": 375.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 375.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0019M", "type": "HCPCS" } ], "description": "Cv ds plasma alys prtn bmrk", "standard_charges": [ { "billing_class": "facility", "maximum": 712.4, "minimum": 712.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0356U", "type": "HCPCS" } ], "description": "Onc orop 17 dna ddpcr alg", "standard_charges": [ { "billing_class": "facility", "maximum": 1800.0, "minimum": 1800.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1800.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0364U", "type": "HCPCS" } ], "description": "Onc hl neo gen seq alys alg", "standard_charges": [ { "billing_class": "facility", "maximum": 2007.25, "minimum": 2007.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2007.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0379U", "type": "HCPCS" } ], "description": "Tgsap sl or neo dna523&rna55", "standard_charges": [ { "billing_class": "facility", "maximum": 3288.51, "minimum": 3288.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3288.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0381U", "type": "HCPCS" } ], "description": "Maple syrup ur ds mntr quan", "standard_charges": [ { "billing_class": "facility", "maximum": 44.12, "minimum": 44.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 44.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0382U", "type": "HCPCS" } ], "description": "Hyprphenylalninmia mntr quan", "standard_charges": [ { "billing_class": "facility", "maximum": 51.64, "minimum": 51.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0383U", "type": "HCPCS" } ], "description": "Tyrosinemia typ i mntr quan", "standard_charges": [ { "billing_class": "facility", "maximum": 52.05, "minimum": 52.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0388U", "type": "HCPCS" } ], "description": "Onc nonsm cll lng ca 37 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 3500.0, "minimum": 3500.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0389U", "type": "HCPCS" } ], "description": "Ped fbrl kd ifi27&mcemp1 rna", "standard_charges": [ { "billing_class": "facility", "maximum": 70.2, "minimum": 70.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0395U", "type": "HCPCS" } ], "description": "Onc lng multiomics plsm alg", "standard_charges": [ { "billing_class": "facility", "maximum": 797.45, "minimum": 797.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 797.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0398U", "type": "HCPCS" } ], "description": "Gi baret esph dna mthyln aly", "standard_charges": [ { "billing_class": "facility", "maximum": 1755.0, "minimum": 1755.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1755.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0399U", "type": "HCPCS" } ], "description": "Neuro cere folate defncy srm", "standard_charges": [ { "billing_class": "facility", "maximum": 300.0, "minimum": 300.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 300.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0401U", "type": "HCPCS" } ], "description": "Crd c hrt ds 9 gen 12 vrnts", "standard_charges": [ { "billing_class": "facility", "maximum": 489.68, "minimum": 489.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 489.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0408U", "type": "HCPCS" } ], "description": "Iaad blk ac wv bsnsr sarscv2", "standard_charges": [ { "billing_class": "facility", "maximum": 14.13, "minimum": 14.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0412U", "type": "HCPCS" } ], "description": "Beta amyloid a?42/40 imprcip", "standard_charges": [ { "billing_class": "facility", "maximum": 750.0, "minimum": 750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 750.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0417U", "type": "HCPCS" } ], "description": "Rare ds alys 335 nuc genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2842.53, "minimum": 2842.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2842.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0420U", "type": "HCPCS" } ], "description": "Onc urthl mrna xprsn 6 snp", "standard_charges": [ { "billing_class": "facility", "maximum": 1328.32, "minimum": 1328.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1328.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0422U", "type": "HCPCS" } ], "description": "Onc pan solid tum alys dna", "standard_charges": [ { "billing_class": "facility", "maximum": 1943.21, "minimum": 1943.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1943.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0423U", "type": "HCPCS" } ], "description": "Psyc genomic alys pnl 26 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0424U", "type": "HCPCS" } ], "description": "Onc prst8 xom alys 53 sncrna", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0425U", "type": "HCPCS" } ], "description": "Genom rpd seq alys ea cmprtr", "standard_charges": [ { "billing_class": "facility", "maximum": 4094.39, "minimum": 4094.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4094.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0426U", "type": "HCPCS" } ], "description": "Genome ultra-rapid seq alys", "standard_charges": [ { "billing_class": "facility", "maximum": 7582.2, "minimum": 7582.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7582.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0427U", "type": "HCPCS" } ], "description": "Monocyte dstrbj wdth whl bld", "standard_charges": [ { "billing_class": "facility", "maximum": 4.48, "minimum": 4.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0429U", "type": "HCPCS" } ], "description": "Hpv orop swab 14 hi-risk typ", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0430U", "type": "HCPCS" } ], "description": "Gi malabs aat calpro pncrtc", "standard_charges": [ { "billing_class": "facility", "maximum": 61.54, "minimum": 61.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0431U", "type": "HCPCS" } ], "description": "Gly rcptr alpha1 igg srm/csf", "standard_charges": [ { "billing_class": "facility", "maximum": 36.57, "minimum": 36.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0432U", "type": "HCPCS" } ], "description": "Klhl11 antb sr/csf asy qual", "standard_charges": [ { "billing_class": "facility", "maximum": 36.57, "minimum": 36.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0433U", "type": "HCPCS" } ], "description": "Onc prst8 5 dna reg mrk pcr", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0434U", "type": "HCPCS" } ], "description": "Rx metab advrs vrnt alys 25", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0435U", "type": "HCPCS" } ], "description": "Onc chemo rx cytox csc 14 rx", "standard_charges": [ { "billing_class": "facility", "maximum": 3033.86, "minimum": 3033.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3033.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0436U", "type": "HCPCS" } ], "description": "Onc lng plsm alys 388 prtn", "standard_charges": [ { "billing_class": "facility", "maximum": 1504.24, "minimum": 1504.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1504.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0437U", "type": "HCPCS" } ], "description": "Psyc anxiety do mrna 15 bmrk", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0438U", "type": "HCPCS" } ], "description": "Rx metab advrs vrnt alys 33", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0439U", "type": "HCPCS" } ], "description": "Crd chd dna alys 5 snp 3 dna", "standard_charges": [ { "billing_class": "facility", "maximum": 854.0, "minimum": 854.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 854.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0440U", "type": "HCPCS" } ], "description": "Crd chd dna alys 10 snp 6dna", "standard_charges": [ { "billing_class": "facility", "maximum": 854.0, "minimum": 854.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 854.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0441U", "type": "HCPCS" } ], "description": "Nfct ds bct fngl/viral semiq", "standard_charges": [ { "billing_class": "facility", "maximum": 444.08, "minimum": 444.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 444.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0442U", "type": "HCPCS" } ], "description": "Nfct ds respir nfctj mxa&crp", "standard_charges": [ { "billing_class": "facility", "maximum": 41.38, "minimum": 41.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 41.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0443U", "type": "HCPCS" } ], "description": "Neurflmnt lt chn ultrsens ia", "standard_charges": [ { "billing_class": "facility", "maximum": 116.23, "minimum": 116.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0444U", "type": "HCPCS" } ], "description": "Onc sld orgn neo tgsap 361", "standard_charges": [ { "billing_class": "facility", "maximum": 2919.6, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0445U", "type": "HCPCS" } ], "description": "Abeta42 & ptau181 eclia csf", "standard_charges": [ { "billing_class": "facility", "maximum": 260.5, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0446U", "type": "HCPCS" } ], "description": "Ai ds sle alys 10 cytokine", "standard_charges": [ { "billing_class": "facility", "maximum": 840.65, "minimum": 840.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 840.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0447U", "type": "HCPCS" } ], "description": "Ai ds sle alys 11 cytokine", "standard_charges": [ { "billing_class": "facility", "maximum": 840.65, "minimum": 840.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 840.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0452U", "type": "HCPCS" } ], "description": "Onc bldr mthyl penk lte-qmsp", "standard_charges": [ { "billing_class": "facility", "maximum": 192.0, "minimum": 192.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0453U", "type": "HCPCS" } ], "description": "Onc clrct ca cfdna qpcr asy", "standard_charges": [ { "billing_class": "facility", "maximum": 192.0, "minimum": 192.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0454U", "type": "HCPCS" } ], "description": "U rare ds id opt genome mapg", "standard_charges": [ { "billing_class": "facility", "maximum": 1263.53, "minimum": 1263.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1263.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0455U", "type": "HCPCS" } ], "description": "Nfct agt sti mult amp prb ur", "standard_charges": [ { "billing_class": "facility", "maximum": 142.63, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0457U", "type": "HCPCS" } ], "description": "Pfas 9 cmpnd lcms/ms pls/sr", "standard_charges": [ { "billing_class": "facility", "maximum": 198.74, "minimum": 198.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 198.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0458U", "type": "HCPCS" } ], "description": "Onc brst ca s100 a8&a9 elisa", "standard_charges": [ { "billing_class": "facility", "maximum": 260.5, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0459U", "type": "HCPCS" } ], "description": "Abeta42 & ttau eclia csf", "standard_charges": [ { "billing_class": "facility", "maximum": 260.5, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0460U", "type": "HCPCS" } ], "description": "Onc whl bld/bucc rtpcr 24gen", "standard_charges": [ { "billing_class": "facility", "maximum": 917.08, "minimum": 917.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 917.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0461U", "type": "HCPCS" } ], "description": "Onc rxgenom alys rtpcr 24gen", "standard_charges": [ { "billing_class": "facility", "maximum": 917.08, "minimum": 917.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 917.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0462U", "type": "HCPCS" } ], "description": "Melatonin lvl tst slp std7/9", "standard_charges": [ { "billing_class": "facility", "maximum": 17.27, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0463U", "type": "HCPCS" } ], "description": "Onc crvx mrna genxprsn 14bmk", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0464U", "type": "HCPCS" } ], "description": "Onc clrct scr qrtsa dna mrk", "standard_charges": [ { "billing_class": "facility", "maximum": 591.92, "minimum": 591.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 591.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0465U", "type": "HCPCS" } ], "description": "Onc urthl carc dna qmsp 2gen", "standard_charges": [ { "billing_class": "facility", "maximum": 1938.01, "minimum": 1938.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1938.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0466U", "type": "HCPCS" } ], "description": "Crd cad dna gwas 564856 snp", "standard_charges": [ { "billing_class": "facility", "maximum": 345.43, "minimum": 345.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0467U", "type": "HCPCS" } ], "description": "Onc bldr dna ngs 60gen&aneup", "standard_charges": [ { "billing_class": "facility", "maximum": 1519.06, "minimum": 1519.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1519.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0468U", "type": "HCPCS" } ], "description": "Hep nash mir34a5p ?2m ykl40", "standard_charges": [ { "billing_class": "facility", "maximum": 251.7, "minimum": 251.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 251.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0469U", "type": "HCPCS" } ], "description": "Rare ds whl gen seq ftl samp", "standard_charges": [ { "billing_class": "facility", "maximum": 1197.94, "minimum": 1197.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1197.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0470U", "type": "HCPCS" } ], "description": "Onc orop detcj mrd 8 dna hpv", "standard_charges": [ { "billing_class": "facility", "maximum": 597.91, "minimum": 597.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0471U", "type": "HCPCS" } ], "description": "Onc clrc ca 35 vrn kras&nras", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0472U", "type": "HCPCS" } ], "description": "Ca vi psp&sp1 antb sj?gren", "standard_charges": [ { "billing_class": "facility", "maximum": 27.9, "minimum": 27.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0473U", "type": "HCPCS" } ], "description": "Onc sld tum bld/slv 648 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 4500.0, "minimum": 4500.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4500.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0474U", "type": "HCPCS" } ], "description": "Hered pan ca gsap 88gene ngs", "standard_charges": [ { "billing_class": "facility", "maximum": 1303.95, "minimum": 1303.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1303.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0475U", "type": "HCPCS" } ], "description": "Hered prst8 ca gsap 23 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 1303.95, "minimum": 1303.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1303.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0476U", "type": "HCPCS" } ], "description": "Rx metab psyc 14gen&cyp2d6", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0477U", "type": "HCPCS" } ], "description": "Rx metab psy 14&cyp2d6 gn-rx", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0478U", "type": "HCPCS" } ], "description": "Onc nsclc dna&rna dpcr 9 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 552.99, "minimum": 552.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 552.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0479U", "type": "HCPCS" } ], "description": "Tau phosphorylated ptau217", "standard_charges": [ { "billing_class": "facility", "maximum": 17.27, "minimum": 17.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0480U", "type": "HCPCS" } ], "description": "Nfct ds csf metag ngs alys", "standard_charges": [ { "billing_class": "facility", "maximum": 2126.2, "minimum": 2126.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2126.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0481U", "type": "HCPCS" } ], "description": "Idh1 idh2&tert promoter ngs", "standard_charges": [ { "billing_class": "facility", "maximum": 674.24, "minimum": 674.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 674.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0482U", "type": "HCPCS" } ], "description": "Ob pe biochem asy sfit1&pigf", "standard_charges": [ { "billing_class": "facility", "maximum": 128.82, "minimum": 128.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0483U", "type": "HCPCS" } ], "description": "Nfct ds ng gyra s91f pt mut", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0484U", "type": "HCPCS" } ], "description": "Nfct ds mgen 23s rrna pt mut", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0485U", "type": "HCPCS" } ], "description": "Onc sol tum cfdna&rna ngs gm", "standard_charges": [ { "billing_class": "facility", "maximum": 3649.48, "minimum": 3649.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3649.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0486U", "type": "HCPCS" } ], "description": "Onc pan sol tum ngs cfctdna", "standard_charges": [ { "billing_class": "facility", "maximum": 1644.25, "minimum": 1644.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1644.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0487U", "type": "HCPCS" } ], "description": "Onc sol tum cfcdna tgsap 84", "standard_charges": [ { "billing_class": "facility", "maximum": 2919.6, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0490U", "type": "HCPCS" } ], "description": "Onc cutan/uveal mlnma cd146", "standard_charges": [ { "billing_class": "facility", "maximum": 2435.0, "minimum": 2435.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2435.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0491U", "type": "HCPCS" } ], "description": "Onc sol tum ctc slct er prtn", "standard_charges": [ { "billing_class": "facility", "maximum": 2435.0, "minimum": 2435.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2435.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0492U", "type": "HCPCS" } ], "description": "Onc sol tum ctc slctn pd-l1", "standard_charges": [ { "billing_class": "facility", "maximum": 2435.0, "minimum": 2435.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2435.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0493U", "type": "HCPCS" } ], "description": "Trnspl med quan dd-cfdna ngs", "standard_charges": [ { "billing_class": "facility", "maximum": 2753.25, "minimum": 2753.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2753.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0494U", "type": "HCPCS" } ], "description": "Rbc ag ftl rhd gene alys ngs", "standard_charges": [ { "billing_class": "facility", "maximum": 759.05, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0495U", "type": "HCPCS" } ], "description": "Onc prst8 alys crcg plsm prt", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0496U", "type": "HCPCS" } ], "description": "Onc clrct cfdna 8/7 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 485.86, "minimum": 485.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 485.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0497U", "type": "HCPCS" } ], "description": "Onc prst8 mrna rt-pcr 6 gene", "standard_charges": [ { "billing_class": "facility", "maximum": 3873.0, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0498U", "type": "HCPCS" } ], "description": "Onc clrct ngs mut detc 43gen", "standard_charges": [ { "billing_class": "facility", "maximum": 1345.31, "minimum": 1345.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1345.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0499U", "type": "HCPCS" } ], "description": "Onc clrct&lng dna ngs 8gene", "standard_charges": [ { "billing_class": "facility", "maximum": 597.91, "minimum": 597.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0500U", "type": "HCPCS" } ], "description": "Autoinflam ds vexas synd dna", "standard_charges": [ { "billing_class": "facility", "maximum": 175.4, "minimum": 175.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 175.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0502U", "type": "HCPCS" } ], "description": "Hpv e6/e7 mrk hi-rsk typ crv", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0503U", "type": "HCPCS" } ], "description": "Neuro alz ds ?amyl&tau prtn", "standard_charges": [ { "billing_class": "facility", "maximum": 750.0, "minimum": 750.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 750.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0504U", "type": "HCPCS" } ], "description": "Nfct ds uti id 17 path orgs", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0505U", "type": "HCPCS" } ], "description": "Nfct ds vag infctj id 32orgs", "standard_charges": [ { "billing_class": "facility", "maximum": 679.77, "minimum": 679.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 679.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0506U", "type": "HCPCS" } ], "description": "Gi barretts esophgl cell 89", "standard_charges": [ { "billing_class": "facility", "maximum": 1938.01, "minimum": 1938.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1938.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0507U", "type": "HCPCS" } ], "description": "Onc ovr dna whole gen w/5hmc", "standard_charges": [ { "billing_class": "facility", "maximum": 1160.0, "minimum": 1160.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1160.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0510U", "type": "HCPCS" } ], "description": "Onc pncrtc ca alg alys 16gen", "standard_charges": [ { "billing_class": "facility", "maximum": 473.91, "minimum": 473.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 473.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0511U", "type": "HCPCS" } ], "description": "Onc sol tum 3dmicroenvir 36+", "standard_charges": [ { "billing_class": "facility", "maximum": 3033.86, "minimum": 3033.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3033.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0512U", "type": "HCPCS" } ], "description": "Onc prst8 alys dgtz img msi", "standard_charges": [ { "billing_class": "facility", "maximum": 706.25, "minimum": 706.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0513U", "type": "HCPCS" } ], "description": "Onc prst8 alg alys msi&hrd", "standard_charges": [ { "billing_class": "facility", "maximum": 706.25, "minimum": 706.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0514U", "type": "HCPCS" } ], "description": "Gi ibd ia quan deter adl lvl", "standard_charges": [ { "billing_class": "facility", "maximum": 38.57, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0515U", "type": "HCPCS" } ], "description": "Gi ibd ia quan deter ifx lvl", "standard_charges": [ { "billing_class": "facility", "maximum": 38.57, "minimum": 38.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0516U", "type": "HCPCS" } ], "description": "Rx metab rxgenomic gnotyp 40", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0517U", "type": "HCPCS" } ], "description": "Ther rx mntr 80+ psyactiv rx", "standard_charges": [ { "billing_class": "facility", "maximum": 246.92, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0518U", "type": "HCPCS" } ], "description": "Ther rx mntr 90+ pn&mtl hlth", "standard_charges": [ { "billing_class": "facility", "maximum": 246.92, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0519U", "type": "HCPCS" } ], "description": "Ther rx mntr meds p/d/a 110+", "standard_charges": [ { "billing_class": "facility", "maximum": 246.92, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0520U", "type": "HCPCS" } ], "description": "Ther rx mntr 200+ rx/sbsts", "standard_charges": [ { "billing_class": "facility", "maximum": 246.92, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0521U", "type": "HCPCS" } ], "description": "Rf iga&igm ccp antb sr-a ia", "standard_charges": [ { "billing_class": "facility", "maximum": 51.8, "minimum": 51.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0522U", "type": "HCPCS" } ], "description": "Ca vi psp&sp1 antb cl semiql", "standard_charges": [ { "billing_class": "facility", "maximum": 260.5, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0523U", "type": "HCPCS" } ], "description": "Onc soltum dna ngs snv 22gen", "standard_charges": [ { "billing_class": "facility", "maximum": 1352.09, "minimum": 1352.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1352.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0524U", "type": "HCPCS" } ], "description": "Ob pe sflt-1/plgf ia srm/pls", "standard_charges": [ { "billing_class": "facility", "maximum": 128.82, "minimum": 128.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0525U", "type": "HCPCS" } ], "description": "Onc sphrd cell cul 11-rx pnl", "standard_charges": [ { "billing_class": "facility", "maximum": 3033.86, "minimum": 3033.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3033.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0527U", "type": "HCPCS" } ], "description": "Hsv 1&2 vzv amp prb tq pthgn", "standard_charges": [ { "billing_class": "facility", "maximum": 142.63, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0528U", "type": "HCPCS" } ], "description": "Lrt iad 18bct/8vir&7arg rna", "standard_charges": [ { "billing_class": "facility", "maximum": 634.84, "minimum": 634.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 634.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0530U", "type": "HCPCS" } ], "description": "Onc pan-sol tum ctdna 77 gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2919.6, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0532U", "type": "HCPCS" } ], "description": "Rare ds whlgen&mitochdrl dna", "standard_charges": [ { "billing_class": "facility", "maximum": 5031.2, "minimum": 5031.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5031.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0533U", "type": "HCPCS" } ], "description": "Rx metab advrs gnotyp 16gens", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0535U", "type": "HCPCS" } ], "description": "Pfas lc-ms/ms plsm/srm quan", "standard_charges": [ { "billing_class": "facility", "maximum": 62.14, "minimum": 62.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0536U", "type": "HCPCS" } ], "description": "Rbcag ftl rhd pcr alys exon4", "standard_charges": [ { "billing_class": "facility", "maximum": 192.0, "minimum": 192.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0537U", "type": "HCPCS" } ], "description": "Onc clrct ca cfdna >2500 dmr", "standard_charges": [ { "billing_class": "facility", "maximum": 1495.0, "minimum": 1495.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1495.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0538U", "type": "HCPCS" } ], "description": "Onc sol tum ngts ffpe 600gen", "standard_charges": [ { "billing_class": "facility", "maximum": 2989.55, "minimum": 2989.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2989.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0539U", "type": "HCPCS" } ], "description": "Onc sol tumor cfctdna 152gen", "standard_charges": [ { "billing_class": "facility", "maximum": 3288.51, "minimum": 3288.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3288.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0540U", "type": "HCPCS" } ], "description": "Trnsplj med quan dd-cfdna", "standard_charges": [ { "billing_class": "facility", "maximum": 2753.25, "minimum": 2753.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2753.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0543U", "type": "HCPCS" } ], "description": "Onc sol tum ngs dna 517 gens", "standard_charges": [ { "billing_class": "facility", "maximum": 2989.55, "minimum": 2989.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2989.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0545U", "type": "HCPCS" } ], "description": "Achr antb id imfluor livecll", "standard_charges": [ { "billing_class": "facility", "maximum": 37.73, "minimum": 37.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0546U", "type": "HCPCS" } ], "description": "Ldns lrp4 antb imflr livecll", "standard_charges": [ { "billing_class": "facility", "maximum": 37.73, "minimum": 37.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0547U", "type": "HCPCS" } ], "description": "Neurflmnt lt chn cleia plsm", "standard_charges": [ { "billing_class": "facility", "maximum": 116.23, "minimum": 116.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0548U", "type": "HCPCS" } ], "description": "Gfap cleia plasma", "standard_charges": [ { "billing_class": "facility", "maximum": 116.23, "minimum": 116.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0549U", "type": "HCPCS" } ], "description": "Onc urthl dna mthyltd rt pcr", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0553U", "type": "HCPCS" } ], "description": "Repr med pga embry te strux", "standard_charges": [ { "billing_class": "facility", "maximum": 759.05, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0554U", "type": "HCPCS" } ], "description": "Repr med pga 24chrm te bx qc", "standard_charges": [ { "billing_class": "facility", "maximum": 759.05, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0555U", "type": "HCPCS" } ], "description": "Repr med pga embryonic te qc", "standard_charges": [ { "billing_class": "facility", "maximum": 759.05, "minimum": 759.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 759.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0556U", "type": "HCPCS" } ], "description": "Nfct ds p-s dna&rna 12 trgts", "standard_charges": [ { "billing_class": "facility", "maximum": 142.63, "minimum": 142.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0557U", "type": "HCPCS" } ], "description": "Nfct ds bv dna mrk vag fluid", "standard_charges": [ { "billing_class": "facility", "maximum": 262.99, "minimum": 262.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 262.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0558U", "type": "HCPCS" } ], "description": "Onc clrct elisa bf7 ag serum", "standard_charges": [ { "billing_class": "facility", "maximum": 20.81, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0559U", "type": "HCPCS" } ], "description": "Onc brs quan elisa bf9ag srm", "standard_charges": [ { "billing_class": "facility", "maximum": 20.81, "minimum": 20.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0560U", "type": "HCPCS" } ], "description": "Onc mrd gsa cfdna baseline", "standard_charges": [ { "billing_class": "facility", "maximum": 3878.45, "minimum": 3878.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3878.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0561U", "type": "HCPCS" } ], "description": "Onc mrd gsa cfdna subsequent", "standard_charges": [ { "billing_class": "facility", "maximum": 794.49, "minimum": 794.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 794.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0562U", "type": "HCPCS" } ], "description": "Onc sol tum tgsa 33gens snvs", "standard_charges": [ { "billing_class": "facility", "maximum": 597.91, "minimum": 597.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0563U", "type": "HCPCS" } ], "description": "Nfct ds pthgn-sna 11vir&4bct", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0564U", "type": "HCPCS" } ], "description": "Nfct ds pthgn-sna 10vir&4bct", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0565U", "type": "HCPCS" } ], "description": "Onc hcc ngs detc 6626epigalt", "standard_charges": [ { "billing_class": "facility", "maximum": 1160.0, "minimum": 1160.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1160.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0566U", "type": "HCPCS" } ], "description": "Onc lng qpcr-bsd alys 13dmrs", "standard_charges": [ { "billing_class": "facility", "maximum": 416.78, "minimum": 416.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 416.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0567U", "type": "HCPCS" } ], "description": "Rare ds whl gen seq srs&lrs", "standard_charges": [ { "billing_class": "facility", "maximum": 5031.2, "minimum": 5031.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5031.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0568U", "type": "HCPCS" } ], "description": "Neurol dementia ?amyl ptau", "standard_charges": [ { "billing_class": "facility", "maximum": 897.0, "minimum": 897.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0570U", "type": "HCPCS" } ], "description": "Neurol tbi alys gfap&uch-l1", "standard_charges": [ { "billing_class": "facility", "maximum": 260.5, "minimum": 260.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 260.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0571U", "type": "HCPCS" } ], "description": "Onc sol tum dna80&rna10g ngs", "standard_charges": [ { "billing_class": "facility", "maximum": 2919.6, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0575U", "type": "HCPCS" } ], "description": "Trnsplj med lar rtpcr 4genes", "standard_charges": [ { "billing_class": "facility", "maximum": 380.0, "minimum": 380.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 380.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0576U", "type": "HCPCS" } ], "description": "Trnsplj med lar quan ddcfdna", "standard_charges": [ { "billing_class": "facility", "maximum": 3240.0, "minimum": 3240.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3240.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0577U", "type": "HCPCS" } ], "description": "Onc ovr serum alys 39 gps", "standard_charges": [ { "billing_class": "facility", "maximum": 246.92, "minimum": 246.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 246.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0578U", "type": "HCPCS" } ], "description": "Onc cutan mln rna qpcr 10gen", "standard_charges": [ { "billing_class": "facility", "maximum": 3873.0, "minimum": 3873.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3873.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0579U", "type": "HCPCS" } ], "description": "Nfro dbtc ckd elisa apoa4", "standard_charges": [ { "billing_class": "facility", "maximum": 390.75, "minimum": 390.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 390.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0580U", "type": "HCPCS" } ], "description": "Bbrgdrferi antb detc 24rprtn", "standard_charges": [ { "billing_class": "facility", "maximum": 17.21, "minimum": 17.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0581U", "type": "HCPCS" } ], "description": "Trnspl med antb nohla 39trgt", "standard_charges": [ { "billing_class": "facility", "maximum": 325.8, "minimum": 325.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 325.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0582U", "type": "HCPCS" } ], "description": "Rare ds rpd whlgen dna vrnts", "standard_charges": [ { "billing_class": "facility", "maximum": 7582.2, "minimum": 7582.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7582.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0583U", "type": "HCPCS" } ], "description": "Rare ds rpd whlgen cmptr dna", "standard_charges": [ { "billing_class": "facility", "maximum": 3791.1, "minimum": 3791.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3791.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0584U", "type": "HCPCS" } ], "description": "Neuro csf prion prtn qual", "standard_charges": [ { "billing_class": "facility", "maximum": 540.99, "minimum": 540.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 540.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0585U", "type": "HCPCS" } ], "description": "Tgsap so neo cfdna 521 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2919.6, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0586U", "type": "HCPCS" } ], "description": "Onc mrna gen xprsn 216 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2919.6, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0587U", "type": "HCPCS" } ], "description": "Ther rx mntr 60-150rx&metabl", "standard_charges": [ { "billing_class": "facility", "maximum": 114.43, "minimum": 114.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0588U", "type": "HCPCS" } ], "description": "Nfct ds bct/vir 32genes mrna", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0589U", "type": "HCPCS" } ], "description": "Pfas24cmpnd hi-perf lc-ms/ms", "standard_charges": [ { "billing_class": "facility", "maximum": 198.74, "minimum": 198.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 198.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0591U", "type": "HCPCS" } ], "description": "Onc prst8 ca 3prtns plsm srm", "standard_charges": [ { "billing_class": "facility", "maximum": 760.0, "minimum": 760.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0592U", "type": "HCPCS" } ], "description": "Onc hl neo dna tgs 417 genes", "standard_charges": [ { "billing_class": "facility", "maximum": 2919.6, "minimum": 2919.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2919.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0593U", "type": "HCPCS" } ], "description": "Nfct ds gu pthgn dna 46trgt", "standard_charges": [ { "billing_class": "facility", "maximum": 634.84, "minimum": 634.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 634.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0595U", "type": "HCPCS" } ], "description": "Nfct ds tfp vctrbrn&zoonotic", "standard_charges": [ { "billing_class": "facility", "maximum": 262.99, "minimum": 262.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 262.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0598U", "type": "HCPCS" } ], "description": "Gi ibs igg antb 18food items", "standard_charges": [ { "billing_class": "facility", "maximum": 300.0, "minimum": 300.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 300.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "0599U", "type": "HCPCS" } ], "description": "Onc pncrtc ca mult ia serum", "standard_charges": [ { "billing_class": "facility", "maximum": 897.0, "minimum": 897.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 897.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81195", "type": "HCPCS" } ], "description": "Cytog genom-wid alys hem mal", "standard_charges": [ { "billing_class": "facility", "maximum": 1863.22, "minimum": 1863.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1863.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81354", "type": "HCPCS" } ], "description": "Cytog alys chrml abnor ogm", "standard_charges": [ { "billing_class": "facility", "maximum": 1263.53, "minimum": 1263.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1263.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81457", "type": "HCPCS" } ], "description": "So neo gsap dna mcrstl ins", "standard_charges": [ { "billing_class": "facility", "maximum": 896.87, "minimum": 896.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 896.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81458", "type": "HCPCS" } ], "description": "So gsap dna cpy nmbr&mcrstl", "standard_charges": [ { "billing_class": "facility", "maximum": 1046.35, "minimum": 1046.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1046.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81459", "type": "HCPCS" } ], "description": "So neo gsap dna/dna&rna", "standard_charges": [ { "billing_class": "facility", "maximum": 2989.55, "minimum": 2989.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2989.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81462", "type": "HCPCS" } ], "description": "So gsap cll fr dna/dna&rna", "standard_charges": [ { "billing_class": "facility", "maximum": 1195.83, "minimum": 1195.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1195.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81463", "type": "HCPCS" } ], "description": "So gsap cl fr cpy nmbr&mcrst", "standard_charges": [ { "billing_class": "facility", "maximum": 1345.31, "minimum": 1345.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1345.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81464", "type": "HCPCS" } ], "description": "So gsap cll fr mcrstl ins", "standard_charges": [ { "billing_class": "facility", "maximum": 3288.51, "minimum": 3288.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3288.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81515", "type": "HCPCS" } ], "description": "Nfct ds bv&vaginitis dna alg", "standard_charges": [ { "billing_class": "facility", "maximum": 262.99, "minimum": 262.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 262.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "81558", "type": "HCPCS" } ], "description": "Trnspl rej kdn mrna qpcr 139", "standard_charges": [ { "billing_class": "facility", "maximum": 3240.0, "minimum": 3240.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3240.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82233", "type": "HCPCS" } ], "description": "Beta-amyloid 1-40 (abeta 40)", "standard_charges": [ { "billing_class": "facility", "maximum": 128.92, "minimum": 128.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "82234", "type": "HCPCS" } ], "description": "Beta-amyloid 1-42 (abeta 42)", "standard_charges": [ { "billing_class": "facility", "maximum": 128.92, "minimum": 128.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "83884", "type": "HCPCS" } ], "description": "Assay neurflmnt light chain", "standard_charges": [ { "billing_class": "facility", "maximum": 116.23, "minimum": 116.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84393", "type": "HCPCS" } ], "description": "Tau phosphorylated ea", "standard_charges": [ { "billing_class": "facility", "maximum": 128.92, "minimum": 128.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "84394", "type": "HCPCS" } ], "description": "Total tau", "standard_charges": [ { "billing_class": "facility", "maximum": 128.92, "minimum": 128.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "86581", "type": "HCPCS" } ], "description": "Strptcs pneum antb serot ia", "standard_charges": [ { "billing_class": "facility", "maximum": 92.03, "minimum": 92.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 92.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87183", "type": "HCPCS" } ], "description": "Sc std carbapenem resist gen", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87494", "type": "HCPCS" } ], "description": "Chlmy trch&neisra gonor mult", "standard_charges": [ { "billing_class": "facility", "maximum": 70.18, "minimum": 70.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87513", "type": "HCPCS" } ], "description": "H pylri clrthmcn rst amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87564", "type": "HCPCS" } ], "description": "Mtb rifampin rst amp prb tq", "standard_charges": [ { "billing_class": "facility", "maximum": 76.77, "minimum": 76.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 76.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87594", "type": "HCPCS" } ], "description": "Pneumcysts jirovecii amp prb", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87626", "type": "HCPCS" } ], "description": "Hpv sep hi-rsk typ&pool rslt", "standard_charges": [ { "billing_class": "facility", "maximum": 70.2, "minimum": 70.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87627", "type": "HCPCS" } ], "description": "Jt spc pthgn&rx rsist gen26+", "standard_charges": [ { "billing_class": "facility", "maximum": 679.77, "minimum": 679.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 679.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "87812", "type": "HCPCS" } ], "description": "Sarscov2&inf typ a&b w/optic", "standard_charges": [ { "billing_class": "facility", "maximum": 74.48, "minimum": 74.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 74.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0567", "type": "HCPCS" } ], "description": "Screening Hep C detect", "standard_charges": [ { "billing_class": "facility", "maximum": 35.09, "minimum": 35.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "V2524", "type": "HCPCS" } ], "description": "Cntct lens hydrophil photoch", "standard_charges": [ { "billing_class": "facility", "maximum": 171.49, "minimum": 171.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 171.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90912", "type": "HCPCS" } ], "description": "Bfb training 1st 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 36.93, "minimum": 36.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90913", "type": "HCPCS" } ], "description": "Bfb training ea addl 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 20.76, "minimum": 20.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92507", "type": "HCPCS" } ], "description": "Speech/hearing therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 73.34, "minimum": 73.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92508", "type": "HCPCS" } ], "description": "Speech/hearing therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 22.95, "minimum": 22.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92521", "type": "HCPCS" } ], "description": "Evaluation of speech fluency", "standard_charges": [ { "billing_class": "facility", "maximum": 128.22, "minimum": 128.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 128.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92522", "type": "HCPCS" } ], "description": "Evaluate speech production", "standard_charges": [ { "billing_class": "facility", "maximum": 107.86, "minimum": 107.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 107.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92523", "type": "HCPCS" } ], "description": "Speech sound lang comprehen", "standard_charges": [ { "billing_class": "facility", "maximum": 217.95, "minimum": 217.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 217.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92524", "type": "HCPCS" } ], "description": "Behavral qualit analys voice", "standard_charges": [ { "billing_class": "facility", "maximum": 105.7, "minimum": 105.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 105.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92526", "type": "HCPCS" } ], "description": "Oral function therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 80.77, "minimum": 80.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 80.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92597", "type": "HCPCS" } ], "description": "Oral speech device eval", "standard_charges": [ { "billing_class": "facility", "maximum": 68.59, "minimum": 68.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92607", "type": "HCPCS" } ], "description": "Ex for speech device rx 1hr", "standard_charges": [ { "billing_class": "facility", "maximum": 117.02, "minimum": 117.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 117.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92608", "type": "HCPCS" } ], "description": "Ex for speech device rx addl", "standard_charges": [ { "billing_class": "facility", "maximum": 45.64, "minimum": 45.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92609", "type": "HCPCS" } ], "description": "Use of speech device service", "standard_charges": [ { "billing_class": "facility", "maximum": 98.01, "minimum": 98.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 98.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92610", "type": "HCPCS" } ], "description": "Evaluate swallowing function", "standard_charges": [ { "billing_class": "facility", "maximum": 56.57, "minimum": 56.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92611", "type": "HCPCS" } ], "description": "Motion fluoroscopy/swallow", "standard_charges": [ { "billing_class": "facility", "maximum": 87.52, "minimum": 87.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 87.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92612", "type": "HCPCS" } ], "description": "Endoscopy swallow (fees) vid", "standard_charges": [ { "billing_class": "facility", "maximum": 53.16, "minimum": 53.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92614", "type": "HCPCS" } ], "description": "Laryngoscopic sensory vid", "standard_charges": [ { "billing_class": "facility", "maximum": 53.2, "minimum": 53.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "92616", "type": "HCPCS" } ], "description": "Fees w/laryngeal sense test", "standard_charges": [ { "billing_class": "facility", "maximum": 78.42, "minimum": 78.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95851", "type": "HCPCS" } ], "description": "Range of motion measurements", "standard_charges": [ { "billing_class": "facility", "maximum": 6.6, "minimum": 6.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95852", "type": "HCPCS" } ], "description": "Range of motion measurements", "standard_charges": [ { "billing_class": "facility", "maximum": 4.93, "minimum": 4.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96105", "type": "HCPCS" } ], "description": "Assessment of aphasia", "standard_charges": [ { "billing_class": "facility", "maximum": 93.98, "minimum": 93.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96125", "type": "HCPCS" } ], "description": "Cognitive test by hc pro", "standard_charges": [ { "billing_class": "facility", "maximum": 98.99, "minimum": 98.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 98.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96202", "type": "HCPCS" } ], "description": "Mlt fam grp bhv train 1st 60", "standard_charges": [ { "billing_class": "facility", "maximum": 17.14, "minimum": 17.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "96203", "type": "HCPCS" } ], "description": "Mlt fam grp bhv train ea add", "standard_charges": [ { "billing_class": "facility", "maximum": 4.95, "minimum": 4.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97012", "type": "HCPCS" } ], "description": "Mechanical traction therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 13.84, "minimum": 13.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97016", "type": "HCPCS" } ], "description": "Vasopneumatic device therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 11.53, "minimum": 11.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97018", "type": "HCPCS" } ], "description": "Paraffin bath therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 5.7, "minimum": 5.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97022", "type": "HCPCS" } ], "description": "Whirlpool therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 14.86, "minimum": 14.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97024", "type": "HCPCS" } ], "description": "Diathermy eg microwave", "standard_charges": [ { "billing_class": "facility", "maximum": 6.91, "minimum": 6.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97026", "type": "HCPCS" } ], "description": "Infrared therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 6.31, "minimum": 6.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97028", "type": "HCPCS" } ], "description": "Ultraviolet therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 7.89, "minimum": 7.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97032", "type": "HCPCS" } ], "description": "Electrical stimulation", "standard_charges": [ { "billing_class": "facility", "maximum": 14.18, "minimum": 14.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97033", "type": "HCPCS" } ], "description": "Electric current therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 18.17, "minimum": 18.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97034", "type": "HCPCS" } ], "description": "Contrast bath therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 13.45, "minimum": 13.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97035", "type": "HCPCS" } ], "description": "Ultrasound therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 13.75, "minimum": 13.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97036", "type": "HCPCS" } ], "description": "Hydrotherapy", "standard_charges": [ { "billing_class": "facility", "maximum": 32.56, "minimum": 32.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97110", "type": "HCPCS" } ], "description": "Therapeutic exercises", "standard_charges": [ { "billing_class": "facility", "maximum": 27.87, "minimum": 27.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97112", "type": "HCPCS" } ], "description": "Neuromuscular reeducation", "standard_charges": [ { "billing_class": "facility", "maximum": 31.37, "minimum": 31.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 31.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97113", "type": "HCPCS" } ], "description": "Aquatic therapy/exercises", "standard_charges": [ { "billing_class": "facility", "maximum": 35.28, "minimum": 35.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97116", "type": "HCPCS" } ], "description": "Gait training therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 27.87, "minimum": 27.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97124", "type": "HCPCS" } ], "description": "Massage therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 28.19, "minimum": 28.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97129", "type": "HCPCS" } ], "description": "Ther ivntj 1st 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 19.48, "minimum": 19.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97130", "type": "HCPCS" } ], "description": "Ther ivntj ea addl 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 18.17, "minimum": 18.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97140", "type": "HCPCS" } ], "description": "Manual therapy 1/> regions", "standard_charges": [ { "billing_class": "facility", "maximum": 26.59, "minimum": 26.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97150", "type": "HCPCS" } ], "description": "Group therapeutic procedures", "standard_charges": [ { "billing_class": "facility", "maximum": 17.34, "minimum": 17.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97161", "type": "HCPCS" } ], "description": "Pt eval low complex 20 min", "standard_charges": [ { "billing_class": "facility", "maximum": 93.86, "minimum": 93.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97162", "type": "HCPCS" } ], "description": "Pt eval mod complex 30 min", "standard_charges": [ { "billing_class": "facility", "maximum": 93.86, "minimum": 93.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97163", "type": "HCPCS" } ], "description": "Pt eval high complex 45 min", "standard_charges": [ { "billing_class": "facility", "maximum": 93.86, "minimum": 93.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97164", "type": "HCPCS" } ], "description": "Pt re-eval est plan care", "standard_charges": [ { "billing_class": "facility", "maximum": 64.42, "minimum": 64.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97165", "type": "HCPCS" } ], "description": "Ot eval low complex 30 min", "standard_charges": [ { "billing_class": "facility", "maximum": 96.3, "minimum": 96.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 96.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97166", "type": "HCPCS" } ], "description": "Ot eval mod complex 45 min", "standard_charges": [ { "billing_class": "facility", "maximum": 96.3, "minimum": 96.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 96.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97167", "type": "HCPCS" } ], "description": "Ot eval high complex 60 min", "standard_charges": [ { "billing_class": "facility", "maximum": 96.3, "minimum": 96.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 96.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97168", "type": "HCPCS" } ], "description": "Ot re-eval est plan care", "standard_charges": [ { "billing_class": "facility", "maximum": 65.34, "minimum": 65.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 65.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97530", "type": "HCPCS" } ], "description": "Therapeutic activities", "standard_charges": [ { "billing_class": "facility", "maximum": 33.33, "minimum": 33.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 33.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97533", "type": "HCPCS" } ], "description": "Sensory Integration", "standard_charges": [ { "billing_class": "facility", "maximum": 56.93, "minimum": 56.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97535", "type": "HCPCS" } ], "description": "Self care mngment training", "standard_charges": [ { "billing_class": "facility", "maximum": 30.92, "minimum": 30.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97537", "type": "HCPCS" } ], "description": "Community/work reintegration", "standard_charges": [ { "billing_class": "facility", "maximum": 30.7, "minimum": 30.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 30.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97542", "type": "HCPCS" } ], "description": "Wheelchair mngment training", "standard_charges": [ { "billing_class": "facility", "maximum": 29.79, "minimum": 29.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97750", "type": "HCPCS" } ], "description": "Physical performance test", "standard_charges": [ { "billing_class": "facility", "maximum": 32.14, "minimum": 32.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97755", "type": "HCPCS" } ], "description": "Assistive technology assess", "standard_charges": [ { "billing_class": "facility", "maximum": 36.29, "minimum": 36.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97760", "type": "HCPCS" } ], "description": "Orthotic mgmt and training", "standard_charges": [ { "billing_class": "facility", "maximum": 43.57, "minimum": 43.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97761", "type": "HCPCS" } ], "description": "Prosthetic training", "standard_charges": [ { "billing_class": "facility", "maximum": 38.38, "minimum": 38.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 38.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97763", "type": "HCPCS" } ], "description": "Orthc/prostc mgmt sbsq enc", "standard_charges": [ { "billing_class": "facility", "maximum": 47.17, "minimum": 47.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97802", "type": "HCPCS" } ], "description": "Medical nutrition indiv in", "standard_charges": [ { "billing_class": "facility", "maximum": 25.66, "minimum": 25.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97803", "type": "HCPCS" } ], "description": "Med nutrition indiv subseq", "standard_charges": [ { "billing_class": "facility", "maximum": 21.47, "minimum": 21.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97804", "type": "HCPCS" } ], "description": "Medical nutrition group", "standard_charges": [ { "billing_class": "facility", "maximum": 12.04, "minimum": 12.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "E1905", "type": "HCPCS" } ], "description": "Vr cbt therapy", "standard_charges": [ { "billing_class": "facility", "maximum": 674.77, "minimum": 674.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 674.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0108", "type": "HCPCS" } ], "description": "Diab manage trn per indiv", "standard_charges": [ { "billing_class": "facility", "maximum": 53.67, "minimum": 53.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0109", "type": "HCPCS" } ], "description": "Diab manage trn ind/group", "standard_charges": [ { "billing_class": "facility", "maximum": 15.4, "minimum": 15.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0270", "type": "HCPCS" } ], "description": "MNT subs tx for change dx", "standard_charges": [ { "billing_class": "facility", "maximum": 21.47, "minimum": 21.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0271", "type": "HCPCS" } ], "description": "Group MNT 2 or more 30 mins", "standard_charges": [ { "billing_class": "facility", "maximum": 12.04, "minimum": 12.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0281", "type": "HCPCS" } ], "description": "Elec stim unattend for press", "standard_charges": [ { "billing_class": "facility", "maximum": 11.23, "minimum": 11.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0283", "type": "HCPCS" } ], "description": "Elec stim other than wound", "standard_charges": [ { "billing_class": "facility", "maximum": 12.14, "minimum": 12.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0329", "type": "HCPCS" } ], "description": "Electromagntic tx for ulcers", "standard_charges": [ { "billing_class": "facility", "maximum": 9.96, "minimum": 9.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77063", "type": "HCPCS" } ], "description": "Breast tomosynthesis bi", "standard_charges": [ { "billing_class": "facility", "maximum": 21.35, "minimum": 21.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77065", "type": "HCPCS" } ], "description": "Dx mammo incl cad uni", "standard_charges": [ { "billing_class": "facility", "maximum": 78.71, "minimum": 78.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77066", "type": "HCPCS" } ], "description": "Dx mammo incl cad bi", "standard_charges": [ { "billing_class": "facility", "maximum": 101.0, "minimum": 101.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "77067", "type": "HCPCS" } ], "description": "Scr mammo bi incl cad", "standard_charges": [ { "billing_class": "facility", "maximum": 83.28, "minimum": 83.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78267", "type": "HCPCS" } ], "description": "Breath tst attain/anal c-14", "standard_charges": [ { "billing_class": "facility", "maximum": 11.06, "minimum": 11.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "78268", "type": "HCPCS" } ], "description": "Breath test analysis c-14", "standard_charges": [ { "billing_class": "facility", "maximum": 94.41, "minimum": 94.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0279", "type": "HCPCS" } ], "description": "Tomosynthesis, mammo", "standard_charges": [ { "billing_class": "facility", "maximum": 11.59, "minimum": 11.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A4593", "type": "HCPCS" } ], "description": "Neuromod sti sys adj rehab", "standard_charges": [ { "billing_class": "facility", "maximum": 52.28, "minimum": 52.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6520", "type": "HCPCS" } ], "description": "G com garmnt glove nghttime", "standard_charges": [ { "billing_class": "facility", "maximum": 126.45, "minimum": 126.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 126.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6521", "type": "HCPCS" } ], "description": "G com garmnt glove nght cust", "standard_charges": [ { "billing_class": "facility", "maximum": 501.75, "minimum": 501.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 501.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6522", "type": "HCPCS" } ], "description": "G com garment arm nighttime", "standard_charges": [ { "billing_class": "facility", "maximum": 307.26, "minimum": 307.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 307.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6523", "type": "HCPCS" } ], "description": "G com garment arm nght custm", "standard_charges": [ { "billing_class": "facility", "maximum": 729.02, "minimum": 729.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 729.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6524", "type": "HCPCS" } ], "description": "G com garmnt lwr leg/ft nght", "standard_charges": [ { "billing_class": "facility", "maximum": 383.34, "minimum": 383.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 383.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6525", "type": "HCPCS" } ], "description": "G com garm lwrleg/ft ngt cus", "standard_charges": [ { "billing_class": "facility", "maximum": 773.9, "minimum": 773.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 773.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6526", "type": "HCPCS" } ], "description": "G com garmt full leg/ft nght", "standard_charges": [ { "billing_class": "facility", "maximum": 693.06, "minimum": 693.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 693.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6527", "type": "HCPCS" } ], "description": "G garmt full leg/ft nght cus", "standard_charges": [ { "billing_class": "facility", "maximum": 1274.45, "minimum": 1274.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1274.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6528", "type": "HCPCS" } ], "description": "G com garment bra nighttime", "standard_charges": [ { "billing_class": "facility", "maximum": 666.42, "minimum": 666.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 666.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6529", "type": "HCPCS" } ], "description": "G com garmt bra night custm", "standard_charges": [ { "billing_class": "facility", "maximum": 1053.04, "minimum": 1053.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1053.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6530", "type": "HCPCS" } ], "description": "Compression stocking bk18-30", "standard_charges": [ { "billing_class": "facility", "maximum": 39.07, "minimum": 39.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6531", "type": "HCPCS" } ], "description": "Compression stocking bk30-40", "standard_charges": [ { "billing_class": "facility", "maximum": 61.66, "minimum": 61.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6532", "type": "HCPCS" } ], "description": "Compression stocking bk40-50", "standard_charges": [ { "billing_class": "facility", "maximum": 86.88, "minimum": 86.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 86.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6533", "type": "HCPCS" } ], "description": "Gc stocking thighlngth 18-30", "standard_charges": [ { "billing_class": "facility", "maximum": 54.86, "minimum": 54.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6534", "type": "HCPCS" } ], "description": "Gc stocking thighlngth 30-40", "standard_charges": [ { "billing_class": "facility", "maximum": 62.65, "minimum": 62.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6535", "type": "HCPCS" } ], "description": "Gc stocking thighlngth 40-50", "standard_charges": [ { "billing_class": "facility", "maximum": 72.13, "minimum": 72.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 72.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6536", "type": "HCPCS" } ], "description": "Gc stocking full lngth 18-30", "standard_charges": [ { "billing_class": "facility", "maximum": 73.95, "minimum": 73.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6537", "type": "HCPCS" } ], "description": "Gc stocking full lngth 30-40", "standard_charges": [ { "billing_class": "facility", "maximum": 87.67, "minimum": 87.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 87.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6538", "type": "HCPCS" } ], "description": "Gc stocking full lngth 40-50", "standard_charges": [ { "billing_class": "facility", "maximum": 102.65, "minimum": 102.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 102.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6539", "type": "HCPCS" } ], "description": "Gc stocking waistlngth 18-30", "standard_charges": [ { "billing_class": "facility", "maximum": 97.86, "minimum": 97.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6540", "type": "HCPCS" } ], "description": "Gc stocking waistlngth 30-40", "standard_charges": [ { "billing_class": "facility", "maximum": 116.68, "minimum": 116.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6541", "type": "HCPCS" } ], "description": "Gc stocking waistlngth 40-50", "standard_charges": [ { "billing_class": "facility", "maximum": 138.21, "minimum": 138.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 138.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6545", "type": "HCPCS" } ], "description": "Grad comp non-elastic BK", "standard_charges": [ { "billing_class": "facility", "maximum": 121.41, "minimum": 121.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 121.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6552", "type": "HCPCS" } ], "description": "Grad com stocking bk 30-40", "standard_charges": [ { "billing_class": "facility", "maximum": 57.97, "minimum": 57.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6553", "type": "HCPCS" } ], "description": "G com stcking bk 30-40 custm", "standard_charges": [ { "billing_class": "facility", "maximum": 226.38, "minimum": 226.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 226.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6554", "type": "HCPCS" } ], "description": "Grad com stocking bk 40+", "standard_charges": [ { "billing_class": "facility", "maximum": 79.72, "minimum": 79.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6555", "type": "HCPCS" } ], "description": "G com stcking bk 40+ custm", "standard_charges": [ { "billing_class": "facility", "maximum": 226.38, "minimum": 226.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 226.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6556", "type": "HCPCS" } ], "description": "G com stcking thgh18-30 cust", "standard_charges": [ { "billing_class": "facility", "maximum": 310.25, "minimum": 310.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 310.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6557", "type": "HCPCS" } ], "description": "G com stcking thgh30-40 cust", "standard_charges": [ { "billing_class": "facility", "maximum": 310.25, "minimum": 310.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 310.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6558", "type": "HCPCS" } ], "description": "G com stcking thgh 40+ cust", "standard_charges": [ { "billing_class": "facility", "maximum": 320.17, "minimum": 320.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 320.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6562", "type": "HCPCS" } ], "description": "G com stckng waist18-30 cust", "standard_charges": [ { "billing_class": "facility", "maximum": 1015.37, "minimum": 1015.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1015.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6563", "type": "HCPCS" } ], "description": "G com stckng waist30-40 cust", "standard_charges": [ { "billing_class": "facility", "maximum": 1015.37, "minimum": 1015.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1015.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6564", "type": "HCPCS" } ], "description": "G com stckng waist 40+ cust", "standard_charges": [ { "billing_class": "facility", "maximum": 1093.78, "minimum": 1093.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1093.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6565", "type": "HCPCS" } ], "description": "Grad comp gauntlet custom", "standard_charges": [ { "billing_class": "facility", "maximum": 175.45, "minimum": 175.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 175.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6566", "type": "HCPCS" } ], "description": "Grad com garment neck/head", "standard_charges": [ { "billing_class": "facility", "maximum": 254.75, "minimum": 254.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 254.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6567", "type": "HCPCS" } ], "description": "G com garment neck/head cust", "standard_charges": [ { "billing_class": "facility", "maximum": 800.42, "minimum": 800.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 800.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6568", "type": "HCPCS" } ], "description": "G com garment torso/shldr", "standard_charges": [ { "billing_class": "facility", "maximum": 166.26, "minimum": 166.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 166.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6569", "type": "HCPCS" } ], "description": "G com garmnt torso/shdr cust", "standard_charges": [ { "billing_class": "facility", "maximum": 946.74, "minimum": 946.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 946.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6570", "type": "HCPCS" } ], "description": "Grad com garment genital", "standard_charges": [ { "billing_class": "facility", "maximum": 113.28, "minimum": 113.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 113.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6571", "type": "HCPCS" } ], "description": "G com garment genital custm", "standard_charges": [ { "billing_class": "facility", "maximum": 680.84, "minimum": 680.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 680.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6572", "type": "HCPCS" } ], "description": "Grad com garment toe caps", "standard_charges": [ { "billing_class": "facility", "maximum": 105.11, "minimum": 105.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 105.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6573", "type": "HCPCS" } ], "description": "Grad com garmnt toe cap cust", "standard_charges": [ { "billing_class": "facility", "maximum": 249.43, "minimum": 249.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 249.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6574", "type": "HCPCS" } ], "description": "Custom gradient sleev/glov", "standard_charges": [ { "billing_class": "facility", "maximum": 317.99, "minimum": 317.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 317.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6575", "type": "HCPCS" } ], "description": "Gradient comp sleev/glov", "standard_charges": [ { "billing_class": "facility", "maximum": 103.05, "minimum": 103.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 103.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6576", "type": "HCPCS" } ], "description": "Custom grad com sleeve med", "standard_charges": [ { "billing_class": "facility", "maximum": 195.16, "minimum": 195.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 195.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6577", "type": "HCPCS" } ], "description": "Custom grad cm sleeve heavy", "standard_charges": [ { "billing_class": "facility", "maximum": 161.53, "minimum": 161.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 161.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6578", "type": "HCPCS" } ], "description": "Gradient comp sleeve", "standard_charges": [ { "billing_class": "facility", "maximum": 79.55, "minimum": 79.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6579", "type": "HCPCS" } ], "description": "Custom grad com glove med", "standard_charges": [ { "billing_class": "facility", "maximum": 313.26, "minimum": 313.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 313.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6580", "type": "HCPCS" } ], "description": "Custom grad com glove heavy", "standard_charges": [ { "billing_class": "facility", "maximum": 310.96, "minimum": 310.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 310.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6581", "type": "HCPCS" } ], "description": "Gradient comp glove", "standard_charges": [ { "billing_class": "facility", "maximum": 72.99, "minimum": 72.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 72.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6582", "type": "HCPCS" } ], "description": "Gradient comp gauntlet", "standard_charges": [ { "billing_class": "facility", "maximum": 48.68, "minimum": 48.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6583", "type": "HCPCS" } ], "description": "Grad com wrap w straps bk", "standard_charges": [ { "billing_class": "facility", "maximum": 160.13, "minimum": 160.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 160.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6585", "type": "HCPCS" } ], "description": "Grad com wrap w straps ak", "standard_charges": [ { "billing_class": "facility", "maximum": 189.6, "minimum": 189.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 189.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6586", "type": "HCPCS" } ], "description": "Grad com wrap w straps leg", "standard_charges": [ { "billing_class": "facility", "maximum": 558.59, "minimum": 558.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 558.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6587", "type": "HCPCS" } ], "description": "Grad com wrap w straps foot", "standard_charges": [ { "billing_class": "facility", "maximum": 73.17, "minimum": 73.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6588", "type": "HCPCS" } ], "description": "Grad com wrap w straps arm", "standard_charges": [ { "billing_class": "facility", "maximum": 243.87, "minimum": 243.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 243.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6589", "type": "HCPCS" } ], "description": "Grad com wrap w straps bra", "standard_charges": [ { "billing_class": "facility", "maximum": 96.27, "minimum": 96.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 96.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6594", "type": "HCPCS" } ], "description": "G comp bandge liner lwr extr", "standard_charges": [ { "billing_class": "facility", "maximum": 35.05, "minimum": 35.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6595", "type": "HCPCS" } ], "description": "G comp bandge liner upr extr", "standard_charges": [ { "billing_class": "facility", "maximum": 34.48, "minimum": 34.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6596", "type": "HCPCS" } ], "description": "G comp bandge conform gauze", "standard_charges": [ { "billing_class": "facility", "maximum": 0.18, "minimum": 0.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6597", "type": "HCPCS" } ], "description": "G comp bandage long stretch", "standard_charges": [ { "billing_class": "facility", "maximum": 1.55, "minimum": 1.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6598", "type": "HCPCS" } ], "description": "G comp bandage med stretch", "standard_charges": [ { "billing_class": "facility", "maximum": 0.75, "minimum": 0.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6599", "type": "HCPCS" } ], "description": "G comp bandage short stretch", "standard_charges": [ { "billing_class": "facility", "maximum": 1.7, "minimum": 1.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6600", "type": "HCPCS" } ], "description": "G com bandge hgh dn foam sht", "standard_charges": [ { "billing_class": "facility", "maximum": 3.07, "minimum": 3.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6601", "type": "HCPCS" } ], "description": "G com bandge hgh dn foam pad", "standard_charges": [ { "billing_class": "facility", "maximum": 3.45, "minimum": 3.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6602", "type": "HCPCS" } ], "description": "G com bandge hgh dn foamroll", "standard_charges": [ { "billing_class": "facility", "maximum": 5.03, "minimum": 5.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6603", "type": "HCPCS" } ], "description": "G com bandge low dn foamchnl", "standard_charges": [ { "billing_class": "facility", "maximum": 2.36, "minimum": 2.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6604", "type": "HCPCS" } ], "description": "G com bandge low dn foam flt", "standard_charges": [ { "billing_class": "facility", "maximum": 1.38, "minimum": 1.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6605", "type": "HCPCS" } ], "description": "G com bandage padded foam", "standard_charges": [ { "billing_class": "facility", "maximum": 1.57, "minimum": 1.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6606", "type": "HCPCS" } ], "description": "G com bandage padded textile", "standard_charges": [ { "billing_class": "facility", "maximum": 4.67, "minimum": 4.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6607", "type": "HCPCS" } ], "description": "G com bandage tub protct lyr", "standard_charges": [ { "billing_class": "facility", "maximum": 1.25, "minimum": 1.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6608", "type": "HCPCS" } ], "description": "G com bandage tub protct pad", "standard_charges": [ { "billing_class": "facility", "maximum": 5.21, "minimum": 5.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A6610", "type": "HCPCS" } ], "description": "G com stcking bk 18-30 custm", "standard_charges": [ { "billing_class": "facility", "maximum": 226.38, "minimum": 226.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 226.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "E0201", "type": "HCPCS" } ], "description": "Penile contractur devic manu", "standard_charges": [ { "billing_class": "facility", "maximum": 146.52, "minimum": 146.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 146.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "E0736", "type": "HCPCS" } ], "description": "Transcut tibial nerv stimula", "standard_charges": [ { "billing_class": "facility", "maximum": 52.35, "minimum": 52.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "E0738", "type": "HCPCS" } ], "description": "Upper extremity rehab", "standard_charges": [ { "billing_class": "facility", "maximum": 2039.64, "minimum": 2039.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2039.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "E0739", "type": "HCPCS" } ], "description": "Rehab sys active assist rt", "standard_charges": [ { "billing_class": "facility", "maximum": 1597.66, "minimum": 1597.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1597.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "E2104", "type": "HCPCS" } ], "description": "Glucose monitor w cartridge", "standard_charges": [ { "billing_class": "facility", "maximum": 54.52, "minimum": 54.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 54.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0112", "type": "HCPCS" } ], "description": "Cranial cervical orthosis", "standard_charges": [ { "billing_class": "facility", "maximum": 1720.06, "minimum": 1720.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1720.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0113", "type": "HCPCS" } ], "description": "Cranial cervical torticollis", "standard_charges": [ { "billing_class": "facility", "maximum": 350.47, "minimum": 350.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 350.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0120", "type": "HCPCS" } ], "description": "Cerv flex n/adj foam pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 32.51, "minimum": 32.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0130", "type": "HCPCS" } ], "description": "Flex thermoplastic collar mo", "standard_charges": [ { "billing_class": "facility", "maximum": 187.59, "minimum": 187.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 187.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0140", "type": "HCPCS" } ], "description": "Cervical semi-rigid adjustab", "standard_charges": [ { "billing_class": "facility", "maximum": 73.56, "minimum": 73.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0150", "type": "HCPCS" } ], "description": "Cerv semi-rig adj molded chn", "standard_charges": [ { "billing_class": "facility", "maximum": 131.54, "minimum": 131.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 131.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0160", "type": "HCPCS" } ], "description": "Cerv sr wire occ/man pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 192.08, "minimum": 192.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 192.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0170", "type": "HCPCS" } ], "description": "Cervical collar molded to pt", "standard_charges": [ { "billing_class": "facility", "maximum": 988.11, "minimum": 988.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 988.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0172", "type": "HCPCS" } ], "description": "Cerv col sr foam 2pc pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 174.05, "minimum": 174.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0174", "type": "HCPCS" } ], "description": "Cerv sr 2pc thor ext pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 342.24, "minimum": 342.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 342.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0180", "type": "HCPCS" } ], "description": "Cer post col occ/man sup adj", "standard_charges": [ { "billing_class": "facility", "maximum": 554.45, "minimum": 554.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 554.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0190", "type": "HCPCS" } ], "description": "Cerv collar supp adj cerv ba", "standard_charges": [ { "billing_class": "facility", "maximum": 653.92, "minimum": 653.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 653.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0200", "type": "HCPCS" } ], "description": "Cerv col supp adj bar & thor", "standard_charges": [ { "billing_class": "facility", "maximum": 758.49, "minimum": 758.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 758.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0220", "type": "HCPCS" } ], "description": "Thor rib belt custom fabrica", "standard_charges": [ { "billing_class": "facility", "maximum": 158.76, "minimum": 158.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 158.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0450", "type": "HCPCS" } ], "description": "Tlso flex trunk/thor pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 123.17, "minimum": 123.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 123.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0454", "type": "HCPCS" } ], "description": "Tlso trnk sj-t9 pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 426.22, "minimum": 426.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 426.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0455", "type": "HCPCS" } ], "description": "Tlso flex trnk sj-t9 pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 228.66, "minimum": 228.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 228.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0456", "type": "HCPCS" } ], "description": "Tlso flex trnk sj-ss pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 1222.31, "minimum": 1222.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1222.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0457", "type": "HCPCS" } ], "description": "Tlso flex trnk sj-ss pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 655.74, "minimum": 655.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 655.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0458", "type": "HCPCS" } ], "description": "TLSO 2Mod symphis-xipho pre", "standard_charges": [ { "billing_class": "facility", "maximum": 1096.06, "minimum": 1096.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1096.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0460", "type": "HCPCS" } ], "description": "Tlso 2 shl symphys-stern cst", "standard_charges": [ { "billing_class": "facility", "maximum": 1233.68, "minimum": 1233.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1233.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0462", "type": "HCPCS" } ], "description": "TLSO 3Mod sacro-scap pre", "standard_charges": [ { "billing_class": "facility", "maximum": 1534.47, "minimum": 1534.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1534.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0464", "type": "HCPCS" } ], "description": "TLSO 4Mod sacro-scap pre", "standard_charges": [ { "billing_class": "facility", "maximum": 1826.79, "minimum": 1826.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1826.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0466", "type": "HCPCS" } ], "description": "Tlso r fram soft ant pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 466.26, "minimum": 466.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 466.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0467", "type": "HCPCS" } ], "description": "Tlso r fram soft pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 256.45, "minimum": 256.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 256.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0468", "type": "HCPCS" } ], "description": "Tlso rig fram pelvic pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 584.34, "minimum": 584.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 584.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0469", "type": "HCPCS" } ], "description": "Tlso rig fram pelvic pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 326.76, "minimum": 326.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 326.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0470", "type": "HCPCS" } ], "description": "TLSO rigid frame pre subclav", "standard_charges": [ { "billing_class": "facility", "maximum": 808.59, "minimum": 808.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 808.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0472", "type": "HCPCS" } ], "description": "TLSO rigid frame hyperex pre", "standard_charges": [ { "billing_class": "facility", "maximum": 497.56, "minimum": 497.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 497.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0480", "type": "HCPCS" } ], "description": "TLSO rigid plastic custom fa", "standard_charges": [ { "billing_class": "facility", "maximum": 1856.29, "minimum": 1856.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1856.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0482", "type": "HCPCS" } ], "description": "TLSO rigid lined custom fab", "standard_charges": [ { "billing_class": "facility", "maximum": 2073.49, "minimum": 2073.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2073.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0484", "type": "HCPCS" } ], "description": "TLSO rigid plastic cust fab", "standard_charges": [ { "billing_class": "facility", "maximum": 2239.27, "minimum": 2239.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2239.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0486", "type": "HCPCS" } ], "description": "TLSO rigidlined cust fab two", "standard_charges": [ { "billing_class": "facility", "maximum": 2514.79, "minimum": 2514.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2514.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0488", "type": "HCPCS" } ], "description": "TLSO rigid lined pre one pie", "standard_charges": [ { "billing_class": "facility", "maximum": 1233.68, "minimum": 1233.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1233.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0490", "type": "HCPCS" } ], "description": "TLSO rigid plastic pre one", "standard_charges": [ { "billing_class": "facility", "maximum": 347.64, "minimum": 347.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 347.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0491", "type": "HCPCS" } ], "description": "TLSO 2 piece rigid shell", "standard_charges": [ { "billing_class": "facility", "maximum": 943.84, "minimum": 943.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 943.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0492", "type": "HCPCS" } ], "description": "TLSO 3 piece rigid shell", "standard_charges": [ { "billing_class": "facility", "maximum": 614.59, "minimum": 614.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 614.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0621", "type": "HCPCS" } ], "description": "Sio flex pelvic/sacr pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 64.94, "minimum": 64.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0622", "type": "HCPCS" } ], "description": "Sio flex pelvisacral custom", "standard_charges": [ { "billing_class": "facility", "maximum": 328.48, "minimum": 328.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 328.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0623", "type": "HCPCS" } ], "description": "Sio rig pnl pelv/sac pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 116.41, "minimum": 116.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0625", "type": "HCPCS" } ], "description": "Lo flex l1-below l5 pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 36.33, "minimum": 36.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0626", "type": "HCPCS" } ], "description": "Lo sag rig pnl stays pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 95.79, "minimum": 95.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 95.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0627", "type": "HCPCS" } ], "description": "Lo sag ri an/pos pnl pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 505.13, "minimum": 505.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 505.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0628", "type": "HCPCS" } ], "description": "Lso flex no ri stays pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 55.32, "minimum": 55.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 55.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0630", "type": "HCPCS" } ], "description": "Lso r post pnl sj-t9 pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 199.05, "minimum": 199.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 199.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0631", "type": "HCPCS" } ], "description": "Lso sag r an/pos pnl pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 1261.6, "minimum": 1261.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1261.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0633", "type": "HCPCS" } ], "description": "Lso sc r pos/lat pnl pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 352.41, "minimum": 352.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 352.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0635", "type": "HCPCS" } ], "description": "Lso sagit rigid panel prefab", "standard_charges": [ { "billing_class": "facility", "maximum": 1228.02, "minimum": 1228.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1228.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0636", "type": "HCPCS" } ], "description": "Lso sagittal rigid panel cus", "standard_charges": [ { "billing_class": "facility", "maximum": 1666.22, "minimum": 1666.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1666.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0637", "type": "HCPCS" } ], "description": "Lso sc r ant/pos pnl pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 1592.13, "minimum": 1592.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0638", "type": "HCPCS" } ], "description": "Lso sag-coronal panel custom", "standard_charges": [ { "billing_class": "facility", "maximum": 1620.91, "minimum": 1620.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1620.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0639", "type": "HCPCS" } ], "description": "Lso s/c shell/panel prefab", "standard_charges": [ { "billing_class": "facility", "maximum": 1592.13, "minimum": 1592.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1592.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0640", "type": "HCPCS" } ], "description": "Lso s/c shell/panel custom", "standard_charges": [ { "billing_class": "facility", "maximum": 1285.97, "minimum": 1285.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1285.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0641", "type": "HCPCS" } ], "description": "Lo rig pos pnl l1-l5 pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 51.4, "minimum": 51.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0642", "type": "HCPCS" } ], "description": "Lo sag ri an/pos pnl pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 271.08, "minimum": 271.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 271.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0643", "type": "HCPCS" } ], "description": "Lso sag ctr rigi pos pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 106.8, "minimum": 106.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 106.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0648", "type": "HCPCS" } ], "description": "Lso sag r an/pos pnl pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 676.99, "minimum": 676.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 676.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0649", "type": "HCPCS" } ], "description": "Lso sc r pos/lat pnl pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 189.11, "minimum": 189.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 189.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0650", "type": "HCPCS" } ], "description": "Lso sc r ant/pos pnl pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 783.31, "minimum": 783.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 783.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0651", "type": "HCPCS" } ], "description": "LSO sag-co shell pnl pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 783.31, "minimum": 783.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 783.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0700", "type": "HCPCS" } ], "description": "Ctlso a-p-l control molded", "standard_charges": [ { "billing_class": "facility", "maximum": 2446.57, "minimum": 2446.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2446.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0710", "type": "HCPCS" } ], "description": "Ctlso a-p-l control w/ inter", "standard_charges": [ { "billing_class": "facility", "maximum": 2689.42, "minimum": 2689.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2689.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0720", "type": "HCPCS" } ], "description": "Ctlso a-p-l control custom", "standard_charges": [ { "billing_class": "facility", "maximum": 2381.24, "minimum": 2381.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2381.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0810", "type": "HCPCS" } ], "description": "Halo cervical into jckt vest", "standard_charges": [ { "billing_class": "facility", "maximum": 3284.91, "minimum": 3284.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3284.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0820", "type": "HCPCS" } ], "description": "Halo cervical into body jack", "standard_charges": [ { "billing_class": "facility", "maximum": 2584.02, "minimum": 2584.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2584.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0830", "type": "HCPCS" } ], "description": "Halo cerv into milwaukee typ", "standard_charges": [ { "billing_class": "facility", "maximum": 3953.92, "minimum": 3953.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3953.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0859", "type": "HCPCS" } ], "description": "MRI compatible system", "standard_charges": [ { "billing_class": "facility", "maximum": 1399.89, "minimum": 1399.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1399.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0861", "type": "HCPCS" } ], "description": "Halo repl liner/interface", "standard_charges": [ { "billing_class": "facility", "maximum": 264.89, "minimum": 264.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 264.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0970", "type": "HCPCS" } ], "description": "Tlso corset front", "standard_charges": [ { "billing_class": "facility", "maximum": 131.34, "minimum": 131.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 131.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0972", "type": "HCPCS" } ], "description": "Lso corset front", "standard_charges": [ { "billing_class": "facility", "maximum": 119.54, "minimum": 119.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0974", "type": "HCPCS" } ], "description": "Tlso full corset", "standard_charges": [ { "billing_class": "facility", "maximum": 214.76, "minimum": 214.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 214.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0976", "type": "HCPCS" } ], "description": "Lso full corset", "standard_charges": [ { "billing_class": "facility", "maximum": 183.75, "minimum": 183.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 183.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0978", "type": "HCPCS" } ], "description": "Axillary crutch extension", "standard_charges": [ { "billing_class": "facility", "maximum": 231.25, "minimum": 231.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 231.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0980", "type": "HCPCS" } ], "description": "Peroneal straps pair pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 20.99, "minimum": 20.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0982", "type": "HCPCS" } ], "description": "Stocking sup grips 4 pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 19.23, "minimum": 19.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L0984", "type": "HCPCS" } ], "description": "Protect body sock ea pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 83.16, "minimum": 83.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1000", "type": "HCPCS" } ], "description": "Ctlso milwauke initial model", "standard_charges": [ { "billing_class": "facility", "maximum": 2492.04, "minimum": 2492.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2492.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1005", "type": "HCPCS" } ], "description": "Tension based scoliosis orth", "standard_charges": [ { "billing_class": "facility", "maximum": 3933.46, "minimum": 3933.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3933.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1010", "type": "HCPCS" } ], "description": "Ctlso axilla sling", "standard_charges": [ { "billing_class": "facility", "maximum": 102.83, "minimum": 102.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 102.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1020", "type": "HCPCS" } ], "description": "Kyphosis pad", "standard_charges": [ { "billing_class": "facility", "maximum": 132.43, "minimum": 132.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 132.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1025", "type": "HCPCS" } ], "description": "Kyphosis pad floating", "standard_charges": [ { "billing_class": "facility", "maximum": 191.06, "minimum": 191.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 191.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1030", "type": "HCPCS" } ], "description": "Lumbar bolster pad", "standard_charges": [ { "billing_class": "facility", "maximum": 96.23, "minimum": 96.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 96.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1040", "type": "HCPCS" } ], "description": "Lumbar or lumbar rib pad", "standard_charges": [ { "billing_class": "facility", "maximum": 108.96, "minimum": 108.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1050", "type": "HCPCS" } ], "description": "Sternal pad", "standard_charges": [ { "billing_class": "facility", "maximum": 123.31, "minimum": 123.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 123.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1060", "type": "HCPCS" } ], "description": "Thoracic pad", "standard_charges": [ { "billing_class": "facility", "maximum": 133.1, "minimum": 133.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 133.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1070", "type": "HCPCS" } ], "description": "Trapezius sling", "standard_charges": [ { "billing_class": "facility", "maximum": 137.88, "minimum": 137.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 137.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1080", "type": "HCPCS" } ], "description": "Outrigger", "standard_charges": [ { "billing_class": "facility", "maximum": 64.3, "minimum": 64.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1085", "type": "HCPCS" } ], "description": "Outrigger bil w/ vert extens", "standard_charges": [ { "billing_class": "facility", "maximum": 215.27, "minimum": 215.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 215.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1090", "type": "HCPCS" } ], "description": "Lumbar sling", "standard_charges": [ { "billing_class": "facility", "maximum": 123.66, "minimum": 123.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 123.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1100", "type": "HCPCS" } ], "description": "Ring flange plastic/leather", "standard_charges": [ { "billing_class": "facility", "maximum": 233.39, "minimum": 233.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 233.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1110", "type": "HCPCS" } ], "description": "Ring flange plas/leather mol", "standard_charges": [ { "billing_class": "facility", "maximum": 391.31, "minimum": 391.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1120", "type": "HCPCS" } ], "description": "Covers for upright each", "standard_charges": [ { "billing_class": "facility", "maximum": 46.74, "minimum": 46.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1200", "type": "HCPCS" } ], "description": "Furnsh initial orthosis only", "standard_charges": [ { "billing_class": "facility", "maximum": 2199.24, "minimum": 2199.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2199.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1210", "type": "HCPCS" } ], "description": "Lateral thoracic extension", "standard_charges": [ { "billing_class": "facility", "maximum": 300.68, "minimum": 300.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 300.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1220", "type": "HCPCS" } ], "description": "Anterior thoracic extension", "standard_charges": [ { "billing_class": "facility", "maximum": 292.66, "minimum": 292.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 292.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1230", "type": "HCPCS" } ], "description": "Milwaukee type superstructur", "standard_charges": [ { "billing_class": "facility", "maximum": 819.86, "minimum": 819.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 819.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1240", "type": "HCPCS" } ], "description": "Lumbar derotation pad", "standard_charges": [ { "billing_class": "facility", "maximum": 111.77, "minimum": 111.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 111.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1250", "type": "HCPCS" } ], "description": "Anterior asis pad", "standard_charges": [ { "billing_class": "facility", "maximum": 97.2, "minimum": 97.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1260", "type": "HCPCS" } ], "description": "Anterior thoracic derotation", "standard_charges": [ { "billing_class": "facility", "maximum": 115.91, "minimum": 115.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 115.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1270", "type": "HCPCS" } ], "description": "Abdominal pad", "standard_charges": [ { "billing_class": "facility", "maximum": 101.86, "minimum": 101.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 101.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1280", "type": "HCPCS" } ], "description": "Rib gusset (elastic) each", "standard_charges": [ { "billing_class": "facility", "maximum": 107.39, "minimum": 107.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 107.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1290", "type": "HCPCS" } ], "description": "Lateral trochanteric pad", "standard_charges": [ { "billing_class": "facility", "maximum": 95.49, "minimum": 95.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 95.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1300", "type": "HCPCS" } ], "description": "Body jacket mold to patient", "standard_charges": [ { "billing_class": "facility", "maximum": 2118.07, "minimum": 2118.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2118.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1310", "type": "HCPCS" } ], "description": "Post-operative body jacket", "standard_charges": [ { "billing_class": "facility", "maximum": 2206.15, "minimum": 2206.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2206.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1600", "type": "HCPCS" } ], "description": "Ho flex frejka w/cov pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 158.37, "minimum": 158.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 158.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1610", "type": "HCPCS" } ], "description": "Ho frejka cov only pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 67.26, "minimum": 67.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 67.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1620", "type": "HCPCS" } ], "description": "Ho flex pavlik harns pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 193.1, "minimum": 193.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 193.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1630", "type": "HCPCS" } ], "description": "Abduct control hip semi-flex", "standard_charges": [ { "billing_class": "facility", "maximum": 259.63, "minimum": 259.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 259.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1640", "type": "HCPCS" } ], "description": "Pelv band/spread bar thigh c", "standard_charges": [ { "billing_class": "facility", "maximum": 581.79, "minimum": 581.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 581.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1650", "type": "HCPCS" } ], "description": "HO abduction hip adjustable", "standard_charges": [ { "billing_class": "facility", "maximum": 303.07, "minimum": 303.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 303.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1652", "type": "HCPCS" } ], "description": "HO bi thighcuffs w sprdr bar", "standard_charges": [ { "billing_class": "facility", "maximum": 438.09, "minimum": 438.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 438.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1660", "type": "HCPCS" } ], "description": "HO abduction static plastic", "standard_charges": [ { "billing_class": "facility", "maximum": 222.08, "minimum": 222.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 222.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1680", "type": "HCPCS" } ], "description": "Pelvic & hip control thigh c", "standard_charges": [ { "billing_class": "facility", "maximum": 1400.11, "minimum": 1400.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1400.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1681", "type": "HCPCS" } ], "description": "Ho bilateral hip abduction", "standard_charges": [ { "billing_class": "facility", "maximum": 2303.12, "minimum": 2303.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2303.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1685", "type": "HCPCS" } ], "description": "Post-op hip abduct custom fa", "standard_charges": [ { "billing_class": "facility", "maximum": 1366.86, "minimum": 1366.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1366.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1686", "type": "HCPCS" } ], "description": "HO post-op hip abduction", "standard_charges": [ { "billing_class": "facility", "maximum": 1151.56, "minimum": 1151.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1151.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1690", "type": "HCPCS" } ], "description": "Combination bilateral HO", "standard_charges": [ { "billing_class": "facility", "maximum": 2376.51, "minimum": 2376.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2376.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1700", "type": "HCPCS" } ], "description": "Leg perthes orth toronto typ", "standard_charges": [ { "billing_class": "facility", "maximum": 1912.04, "minimum": 1912.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1912.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1710", "type": "HCPCS" } ], "description": "Legg perthes orth newington", "standard_charges": [ { "billing_class": "facility", "maximum": 2434.79, "minimum": 2434.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2434.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1720", "type": "HCPCS" } ], "description": "Legg perthes orthosis trilat", "standard_charges": [ { "billing_class": "facility", "maximum": 1812.94, "minimum": 1812.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1812.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1730", "type": "HCPCS" } ], "description": "Legg perthes orth scottish r", "standard_charges": [ { "billing_class": "facility", "maximum": 1530.52, "minimum": 1530.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1530.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1755", "type": "HCPCS" } ], "description": "Legg perthes patten bottom t", "standard_charges": [ { "billing_class": "facility", "maximum": 2200.45, "minimum": 2200.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2200.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1810", "type": "HCPCS" } ], "description": "Ko elastic with joints", "standard_charges": [ { "billing_class": "facility", "maximum": 126.52, "minimum": 126.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 126.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1812", "type": "HCPCS" } ], "description": "Ko elastic w/joints pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 78.51, "minimum": 78.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 78.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1820", "type": "HCPCS" } ], "description": "Ko elas w/ condyle pads & jo", "standard_charges": [ { "billing_class": "facility", "maximum": 174.65, "minimum": 174.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 174.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1830", "type": "HCPCS" } ], "description": "Ko immob canvas long pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 70.75, "minimum": 70.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1831", "type": "HCPCS" } ], "description": "Knee orth pos locking joint", "standard_charges": [ { "billing_class": "facility", "maximum": 361.7, "minimum": 361.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 361.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1832", "type": "HCPCS" } ], "description": "Ko adj jnt pos r sup pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 846.51, "minimum": 846.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 846.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1833", "type": "HCPCS" } ], "description": "Ko adj jnt pos r sup pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 509.63, "minimum": 509.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 509.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1834", "type": "HCPCS" } ], "description": "Ko w/0 joint rigid molded to", "standard_charges": [ { "billing_class": "facility", "maximum": 892.02, "minimum": 892.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 892.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1836", "type": "HCPCS" } ], "description": "Ko rigid w/o joints pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 100.03, "minimum": 100.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1840", "type": "HCPCS" } ], "description": "Ko derot ant cruciate custom", "standard_charges": [ { "billing_class": "facility", "maximum": 1155.72, "minimum": 1155.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1155.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1843", "type": "HCPCS" } ], "description": "Ko single upright pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 1102.71, "minimum": 1102.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1102.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1844", "type": "HCPCS" } ], "description": "Ko w/adj jt rot cntrl molded", "standard_charges": [ { "billing_class": "facility", "maximum": 1871.51, "minimum": 1871.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1871.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1845", "type": "HCPCS" } ], "description": "Ko double upright pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 1029.48, "minimum": 1029.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1029.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1846", "type": "HCPCS" } ], "description": "Ko w adj flex/ext rotat mold", "standard_charges": [ { "billing_class": "facility", "maximum": 1437.92, "minimum": 1437.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1437.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1847", "type": "HCPCS" } ], "description": "Ko dbl upright w/air pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 706.86, "minimum": 706.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1848", "type": "HCPCS" } ], "description": "Ko dbl upright w/air pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 706.86, "minimum": 706.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1850", "type": "HCPCS" } ], "description": "Ko swedish type pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 230.4, "minimum": 230.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1851", "type": "HCPCS" } ], "description": "Ko single upright prefab ots", "standard_charges": [ { "billing_class": "facility", "maximum": 672.67, "minimum": 672.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 672.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1852", "type": "HCPCS" } ], "description": "Ko double upright prefab ots", "standard_charges": [ { "billing_class": "facility", "maximum": 641.72, "minimum": 641.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 641.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1860", "type": "HCPCS" } ], "description": "Ko supracondylar socket mold", "standard_charges": [ { "billing_class": "facility", "maximum": 1532.49, "minimum": 1532.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1532.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1900", "type": "HCPCS" } ], "description": "Afo sprng wir drsflx calf bd", "standard_charges": [ { "billing_class": "facility", "maximum": 350.64, "minimum": 350.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 350.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1902", "type": "HCPCS" } ], "description": "Afo ankle gauntlet pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 91.73, "minimum": 91.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 91.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1904", "type": "HCPCS" } ], "description": "Afo molded ankle gauntlet", "standard_charges": [ { "billing_class": "facility", "maximum": 554.72, "minimum": 554.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 554.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1906", "type": "HCPCS" } ], "description": "Afo multilig ank sup pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 138.2, "minimum": 138.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 138.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1907", "type": "HCPCS" } ], "description": "AFO supramalleolar custom", "standard_charges": [ { "billing_class": "facility", "maximum": 691.55, "minimum": 691.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 691.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1910", "type": "HCPCS" } ], "description": "Afo sing bar clasp attach sh", "standard_charges": [ { "billing_class": "facility", "maximum": 344.65, "minimum": 344.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 344.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1920", "type": "HCPCS" } ], "description": "Afo sing upright w/ adjust s", "standard_charges": [ { "billing_class": "facility", "maximum": 504.86, "minimum": 504.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 504.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1930", "type": "HCPCS" } ], "description": "Afo plastic", "standard_charges": [ { "billing_class": "facility", "maximum": 309.6, "minimum": 309.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 309.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1932", "type": "HCPCS" } ], "description": "Afo rig ant tib prefab TCF/=", "standard_charges": [ { "billing_class": "facility", "maximum": 1096.64, "minimum": 1096.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1096.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1933", "type": "HCPCS" } ], "description": "Afo rig ant tib tcf/= ots", "standard_charges": [ { "billing_class": "facility", "maximum": 1096.64, "minimum": 1096.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1096.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1940", "type": "HCPCS" } ], "description": "Afo molded to patient plasti", "standard_charges": [ { "billing_class": "facility", "maximum": 598.47, "minimum": 598.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 598.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1945", "type": "HCPCS" } ], "description": "Afo molded plas rig ant tib", "standard_charges": [ { "billing_class": "facility", "maximum": 1379.49, "minimum": 1379.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1379.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1950", "type": "HCPCS" } ], "description": "Afo spiral molded to pt plas", "standard_charges": [ { "billing_class": "facility", "maximum": 945.14, "minimum": 945.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 945.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1951", "type": "HCPCS" } ], "description": "AFO spiral prefabricated", "standard_charges": [ { "billing_class": "facility", "maximum": 1032.09, "minimum": 1032.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1032.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1952", "type": "HCPCS" } ], "description": "Afo spiral prefab ots", "standard_charges": [ { "billing_class": "facility", "maximum": 1032.09, "minimum": 1032.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1032.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1960", "type": "HCPCS" } ], "description": "Afo pos solid ank plastic mo", "standard_charges": [ { "billing_class": "facility", "maximum": 761.8, "minimum": 761.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 761.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1970", "type": "HCPCS" } ], "description": "Afo plastic molded w/ankle j", "standard_charges": [ { "billing_class": "facility", "maximum": 850.61, "minimum": 850.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 850.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1971", "type": "HCPCS" } ], "description": "AFO w/ankle joint, prefab", "standard_charges": [ { "billing_class": "facility", "maximum": 576.1, "minimum": 576.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 576.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1980", "type": "HCPCS" } ], "description": "Afo sing solid stirrup calf", "standard_charges": [ { "billing_class": "facility", "maximum": 496.21, "minimum": 496.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 496.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L1990", "type": "HCPCS" } ], "description": "Afo doub solid stirrup calf", "standard_charges": [ { "billing_class": "facility", "maximum": 574.3, "minimum": 574.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 574.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2000", "type": "HCPCS" } ], "description": "Kafo sing fre stirr thi/calf", "standard_charges": [ { "billing_class": "facility", "maximum": 1374.81, "minimum": 1374.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1374.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2005", "type": "HCPCS" } ], "description": "KAFO sng/dbl mechanical act", "standard_charges": [ { "billing_class": "facility", "maximum": 5035.93, "minimum": 5035.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5035.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2010", "type": "HCPCS" } ], "description": "Kafo sng solid stirrup w/o j", "standard_charges": [ { "billing_class": "facility", "maximum": 1072.34, "minimum": 1072.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1072.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2020", "type": "HCPCS" } ], "description": "Kafo dbl solid stirrup band/", "standard_charges": [ { "billing_class": "facility", "maximum": 1354.33, "minimum": 1354.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1354.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2030", "type": "HCPCS" } ], "description": "Kafo dbl solid stirrup w/o j", "standard_charges": [ { "billing_class": "facility", "maximum": 1331.19, "minimum": 1331.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1331.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2034", "type": "HCPCS" } ], "description": "Kafo pla sin up w/wo k/a cus", "standard_charges": [ { "billing_class": "facility", "maximum": 2496.59, "minimum": 2496.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2496.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2035", "type": "HCPCS" } ], "description": "KAFO plastic pediatric size", "standard_charges": [ { "billing_class": "facility", "maximum": 212.91, "minimum": 212.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 212.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2036", "type": "HCPCS" } ], "description": "Kafo plas doub free knee mol", "standard_charges": [ { "billing_class": "facility", "maximum": 2278.43, "minimum": 2278.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2278.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2037", "type": "HCPCS" } ], "description": "Kafo plas sing free knee mol", "standard_charges": [ { "billing_class": "facility", "maximum": 2038.02, "minimum": 2038.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2038.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2038", "type": "HCPCS" } ], "description": "Kafo w/o joint multi-axis an", "standard_charges": [ { "billing_class": "facility", "maximum": 1642.94, "minimum": 1642.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1642.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2040", "type": "HCPCS" } ], "description": "Hkafo torsion bil rot straps", "standard_charges": [ { "billing_class": "facility", "maximum": 248.63, "minimum": 248.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 248.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2050", "type": "HCPCS" } ], "description": "Hkafo torsion cable hip pelv", "standard_charges": [ { "billing_class": "facility", "maximum": 598.88, "minimum": 598.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 598.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2060", "type": "HCPCS" } ], "description": "Hkafo torsion ball bearing j", "standard_charges": [ { "billing_class": "facility", "maximum": 749.08, "minimum": 749.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 749.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2070", "type": "HCPCS" } ], "description": "Hkafo torsion unilat rot str", "standard_charges": [ { "billing_class": "facility", "maximum": 190.75, "minimum": 190.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 190.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2080", "type": "HCPCS" } ], "description": "Hkafo unilat torsion cable", "standard_charges": [ { "billing_class": "facility", "maximum": 458.63, "minimum": 458.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 458.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2090", "type": "HCPCS" } ], "description": "Hkafo unilat torsion ball br", "standard_charges": [ { "billing_class": "facility", "maximum": 611.07, "minimum": 611.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 611.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2106", "type": "HCPCS" } ], "description": "Afo tib fx cast plaster mold", "standard_charges": [ { "billing_class": "facility", "maximum": 968.68, "minimum": 968.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 968.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2108", "type": "HCPCS" } ], "description": "Afo tib fx cast molded to pt", "standard_charges": [ { "billing_class": "facility", "maximum": 1412.85, "minimum": 1412.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1412.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2112", "type": "HCPCS" } ], "description": "Afo tibial fracture soft", "standard_charges": [ { "billing_class": "facility", "maximum": 620.02, "minimum": 620.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 620.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2114", "type": "HCPCS" } ], "description": "Afo tib fx semi-rigid", "standard_charges": [ { "billing_class": "facility", "maximum": 776.59, "minimum": 776.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 776.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2116", "type": "HCPCS" } ], "description": "Afo tibial fracture rigid", "standard_charges": [ { "billing_class": "facility", "maximum": 947.2, "minimum": 947.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 947.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2126", "type": "HCPCS" } ], "description": "Kafo fem fx cast thermoplas", "standard_charges": [ { "billing_class": "facility", "maximum": 1569.24, "minimum": 1569.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1569.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2128", "type": "HCPCS" } ], "description": "Kafo fem fx cast molded to p", "standard_charges": [ { "billing_class": "facility", "maximum": 1970.44, "minimum": 1970.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1970.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2132", "type": "HCPCS" } ], "description": "Kafo femoral fx cast soft", "standard_charges": [ { "billing_class": "facility", "maximum": 1196.02, "minimum": 1196.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1196.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2134", "type": "HCPCS" } ], "description": "Kafo fem fx cast semi-rigid", "standard_charges": [ { "billing_class": "facility", "maximum": 1416.24, "minimum": 1416.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1416.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2136", "type": "HCPCS" } ], "description": "Kafo femoral fx cast rigid", "standard_charges": [ { "billing_class": "facility", "maximum": 1549.86, "minimum": 1549.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1549.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2180", "type": "HCPCS" } ], "description": "Plas shoe insert w ank joint", "standard_charges": [ { "billing_class": "facility", "maximum": 162.92, "minimum": 162.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 162.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2182", "type": "HCPCS" } ], "description": "Drop lock knee", "standard_charges": [ { "billing_class": "facility", "maximum": 140.43, "minimum": 140.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 140.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2184", "type": "HCPCS" } ], "description": "Limited motion knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 142.35, "minimum": 142.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 142.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2186", "type": "HCPCS" } ], "description": "Adj motion knee jnt lerman t", "standard_charges": [ { "billing_class": "facility", "maximum": 189.31, "minimum": 189.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 189.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2188", "type": "HCPCS" } ], "description": "Quadrilateral brim", "standard_charges": [ { "billing_class": "facility", "maximum": 344.15, "minimum": 344.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 344.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2190", "type": "HCPCS" } ], "description": "Waist belt", "standard_charges": [ { "billing_class": "facility", "maximum": 104.83, "minimum": 104.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 104.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2192", "type": "HCPCS" } ], "description": "Pelvic band & belt thigh fla", "standard_charges": [ { "billing_class": "facility", "maximum": 409.73, "minimum": 409.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 409.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2200", "type": "HCPCS" } ], "description": "Limited ankle motion ea jnt", "standard_charges": [ { "billing_class": "facility", "maximum": 61.75, "minimum": 61.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 61.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2210", "type": "HCPCS" } ], "description": "Dorsiflexion assist each joi", "standard_charges": [ { "billing_class": "facility", "maximum": 77.24, "minimum": 77.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2220", "type": "HCPCS" } ], "description": "Dorsi & plantar flex ass/res", "standard_charges": [ { "billing_class": "facility", "maximum": 99.43, "minimum": 99.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 99.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2230", "type": "HCPCS" } ], "description": "Split flat caliper stirr & p", "standard_charges": [ { "billing_class": "facility", "maximum": 117.56, "minimum": 117.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 117.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2232", "type": "HCPCS" } ], "description": "Rocker bottom, contact AFO", "standard_charges": [ { "billing_class": "facility", "maximum": 119.38, "minimum": 119.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 119.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2240", "type": "HCPCS" } ], "description": "Round caliper and plate atta", "standard_charges": [ { "billing_class": "facility", "maximum": 117.01, "minimum": 117.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 117.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2250", "type": "HCPCS" } ], "description": "Foot plate molded stirrup at", "standard_charges": [ { "billing_class": "facility", "maximum": 410.5, "minimum": 410.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 410.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2260", "type": "HCPCS" } ], "description": "Reinforced solid stirrup", "standard_charges": [ { "billing_class": "facility", "maximum": 230.35, "minimum": 230.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 230.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2265", "type": "HCPCS" } ], "description": "Long tongue stirrup", "standard_charges": [ { "billing_class": "facility", "maximum": 165.21, "minimum": 165.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 165.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2270", "type": "HCPCS" } ], "description": "Varus/valgus strap padded/li", "standard_charges": [ { "billing_class": "facility", "maximum": 75.76, "minimum": 75.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2275", "type": "HCPCS" } ], "description": "Plastic mod low ext pad/line", "standard_charges": [ { "billing_class": "facility", "maximum": 160.19, "minimum": 160.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 160.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2280", "type": "HCPCS" } ], "description": "Molded inner boot", "standard_charges": [ { "billing_class": "facility", "maximum": 693.78, "minimum": 693.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 693.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2300", "type": "HCPCS" } ], "description": "Abduction bar jointed adjust", "standard_charges": [ { "billing_class": "facility", "maximum": 309.39, "minimum": 309.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 309.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2310", "type": "HCPCS" } ], "description": "Abduction bar-straight", "standard_charges": [ { "billing_class": "facility", "maximum": 141.37, "minimum": 141.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 141.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2320", "type": "HCPCS" } ], "description": "Non-molded lacer", "standard_charges": [ { "billing_class": "facility", "maximum": 237.08, "minimum": 237.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 237.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2330", "type": "HCPCS" } ], "description": "Lacer molded to patient mode", "standard_charges": [ { "billing_class": "facility", "maximum": 451.21, "minimum": 451.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 451.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2335", "type": "HCPCS" } ], "description": "Anterior swing band", "standard_charges": [ { "billing_class": "facility", "maximum": 345.46, "minimum": 345.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 345.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2340", "type": "HCPCS" } ], "description": "Pre-tibial shell molded to p", "standard_charges": [ { "billing_class": "facility", "maximum": 513.58, "minimum": 513.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 513.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2350", "type": "HCPCS" } ], "description": "Prosthetic type socket molde", "standard_charges": [ { "billing_class": "facility", "maximum": 1023.92, "minimum": 1023.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1023.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2360", "type": "HCPCS" } ], "description": "Extended steel shank", "standard_charges": [ { "billing_class": "facility", "maximum": 63.37, "minimum": 63.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 63.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2370", "type": "HCPCS" } ], "description": "Patten bottom", "standard_charges": [ { "billing_class": "facility", "maximum": 393.31, "minimum": 393.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 393.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2375", "type": "HCPCS" } ], "description": "Torsion ank & half solid sti", "standard_charges": [ { "billing_class": "facility", "maximum": 151.22, "minimum": 151.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 151.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2380", "type": "HCPCS" } ], "description": "Torsion straight knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 158.6, "minimum": 158.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 158.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2385", "type": "HCPCS" } ], "description": "Straight knee joint heavy du", "standard_charges": [ { "billing_class": "facility", "maximum": 180.58, "minimum": 180.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 180.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2387", "type": "HCPCS" } ], "description": "Add le poly knee custom kafo", "standard_charges": [ { "billing_class": "facility", "maximum": 234.6, "minimum": 234.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 234.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2390", "type": "HCPCS" } ], "description": "Offset knee joint each", "standard_charges": [ { "billing_class": "facility", "maximum": 125.79, "minimum": 125.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 125.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2395", "type": "HCPCS" } ], "description": "Offset knee joint heavy duty", "standard_charges": [ { "billing_class": "facility", "maximum": 179.8, "minimum": 179.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 179.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2397", "type": "HCPCS" } ], "description": "Suspension sleeve lower ext", "standard_charges": [ { "billing_class": "facility", "maximum": 150.0, "minimum": 150.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2405", "type": "HCPCS" } ], "description": "Knee joint drop lock ea jnt", "standard_charges": [ { "billing_class": "facility", "maximum": 107.14, "minimum": 107.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 107.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2415", "type": "HCPCS" } ], "description": "Knee joint cam lock each joi", "standard_charges": [ { "billing_class": "facility", "maximum": 149.3, "minimum": 149.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 149.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2425", "type": "HCPCS" } ], "description": "Knee disc/dial lock/adj flex", "standard_charges": [ { "billing_class": "facility", "maximum": 176.17, "minimum": 176.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 176.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2430", "type": "HCPCS" } ], "description": "Knee jnt ratchet lock ea jnt", "standard_charges": [ { "billing_class": "facility", "maximum": 176.17, "minimum": 176.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 176.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2492", "type": "HCPCS" } ], "description": "Knee lift loop drop lock rin", "standard_charges": [ { "billing_class": "facility", "maximum": 144.15, "minimum": 144.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 144.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2500", "type": "HCPCS" } ], "description": "Thi/glut/ischia wgt bearing", "standard_charges": [ { "billing_class": "facility", "maximum": 384.58, "minimum": 384.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 384.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2510", "type": "HCPCS" } ], "description": "Th/wght bear quad-lat brim m", "standard_charges": [ { "billing_class": "facility", "maximum": 991.19, "minimum": 991.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 991.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2520", "type": "HCPCS" } ], "description": "Th/wght bear quad-lat brim c", "standard_charges": [ { "billing_class": "facility", "maximum": 660.58, "minimum": 660.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 660.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2525", "type": "HCPCS" } ], "description": "Th/wght bear nar m-l brim mo", "standard_charges": [ { "billing_class": "facility", "maximum": 1400.77, "minimum": 1400.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1400.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2526", "type": "HCPCS" } ], "description": "Th/wght bear nar m-l brim cu", "standard_charges": [ { "billing_class": "facility", "maximum": 787.09, "minimum": 787.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 787.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2530", "type": "HCPCS" } ], "description": "Thigh/wght bear lacer non-mo", "standard_charges": [ { "billing_class": "facility", "maximum": 294.73, "minimum": 294.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 294.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2540", "type": "HCPCS" } ], "description": "Thigh/wght bear lacer molded", "standard_charges": [ { "billing_class": "facility", "maximum": 557.7, "minimum": 557.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 557.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2550", "type": "HCPCS" } ], "description": "Thigh/wght bear high roll cu", "standard_charges": [ { "billing_class": "facility", "maximum": 418.16, "minimum": 418.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 418.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2570", "type": "HCPCS" } ], "description": "Hip clevis type 2 posit jnt", "standard_charges": [ { "billing_class": "facility", "maximum": 547.34, "minimum": 547.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 547.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2580", "type": "HCPCS" } ], "description": "Pelvic control pelvic sling", "standard_charges": [ { "billing_class": "facility", "maximum": 533.32, "minimum": 533.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 533.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2600", "type": "HCPCS" } ], "description": "Hip clevis/thrust bearing fr", "standard_charges": [ { "billing_class": "facility", "maximum": 262.12, "minimum": 262.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 262.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2610", "type": "HCPCS" } ], "description": "Hip clevis/thrust bearing lo", "standard_charges": [ { "billing_class": "facility", "maximum": 289.65, "minimum": 289.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 289.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2620", "type": "HCPCS" } ], "description": "Pelvic control hip heavy dut", "standard_charges": [ { "billing_class": "facility", "maximum": 307.25, "minimum": 307.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 307.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2622", "type": "HCPCS" } ], "description": "Hip joint adjustable flexion", "standard_charges": [ { "billing_class": "facility", "maximum": 391.07, "minimum": 391.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 391.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2624", "type": "HCPCS" } ], "description": "Hip adj flex ext abduct cont", "standard_charges": [ { "billing_class": "facility", "maximum": 479.52, "minimum": 479.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 479.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2627", "type": "HCPCS" } ], "description": "Plastic mold recipro hip & c", "standard_charges": [ { "billing_class": "facility", "maximum": 2626.58, "minimum": 2626.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2626.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2628", "type": "HCPCS" } ], "description": "Metal frame recipro hip & ca", "standard_charges": [ { "billing_class": "facility", "maximum": 1925.23, "minimum": 1925.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1925.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2630", "type": "HCPCS" } ], "description": "Pelvic control band & belt u", "standard_charges": [ { "billing_class": "facility", "maximum": 284.55, "minimum": 284.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 284.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2640", "type": "HCPCS" } ], "description": "Pelvic control band & belt b", "standard_charges": [ { "billing_class": "facility", "maximum": 386.17, "minimum": 386.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 386.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2650", "type": "HCPCS" } ], "description": "Pelv & thor control gluteal", "standard_charges": [ { "billing_class": "facility", "maximum": 170.06, "minimum": 170.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 170.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2660", "type": "HCPCS" } ], "description": "Thoracic control thoracic ba", "standard_charges": [ { "billing_class": "facility", "maximum": 220.2, "minimum": 220.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 220.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2670", "type": "HCPCS" } ], "description": "Thorac cont paraspinal uprig", "standard_charges": [ { "billing_class": "facility", "maximum": 196.02, "minimum": 196.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 196.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2680", "type": "HCPCS" } ], "description": "Thorac cont lat support upri", "standard_charges": [ { "billing_class": "facility", "maximum": 179.82, "minimum": 179.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 179.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2750", "type": "HCPCS" } ], "description": "Plating chrome/nickel pr bar", "standard_charges": [ { "billing_class": "facility", "maximum": 96.05, "minimum": 96.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 96.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2755", "type": "HCPCS" } ], "description": "Carbon graphite lamination", "standard_charges": [ { "billing_class": "facility", "maximum": 160.58, "minimum": 160.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 160.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2760", "type": "HCPCS" } ], "description": "Extension per extension per", "standard_charges": [ { "billing_class": "facility", "maximum": 69.82, "minimum": 69.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 69.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2768", "type": "HCPCS" } ], "description": "Ortho sidebar disconnect", "standard_charges": [ { "billing_class": "facility", "maximum": 160.11, "minimum": 160.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 160.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2780", "type": "HCPCS" } ], "description": "Non-corrosive finish", "standard_charges": [ { "billing_class": "facility", "maximum": 77.77, "minimum": 77.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2785", "type": "HCPCS" } ], "description": "Drop lock retainer each", "standard_charges": [ { "billing_class": "facility", "maximum": 36.42, "minimum": 36.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 36.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2795", "type": "HCPCS" } ], "description": "Knee control full kneecap", "standard_charges": [ { "billing_class": "facility", "maximum": 100.8, "minimum": 100.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2800", "type": "HCPCS" } ], "description": "Knee cap medial or lateral p", "standard_charges": [ { "billing_class": "facility", "maximum": 123.76, "minimum": 123.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 123.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2810", "type": "HCPCS" } ], "description": "Knee control condylar pad", "standard_charges": [ { "billing_class": "facility", "maximum": 100.38, "minimum": 100.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2820", "type": "HCPCS" } ], "description": "Soft interface below knee se", "standard_charges": [ { "billing_class": "facility", "maximum": 99.79, "minimum": 99.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 99.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2830", "type": "HCPCS" } ], "description": "Soft interface above knee se", "standard_charges": [ { "billing_class": "facility", "maximum": 107.96, "minimum": 107.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 107.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2840", "type": "HCPCS" } ], "description": "Tibial length sock fx or equ", "standard_charges": [ { "billing_class": "facility", "maximum": 53.02, "minimum": 53.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L2850", "type": "HCPCS" } ], "description": "Femoral lgth sock fx or equa", "standard_charges": [ { "billing_class": "facility", "maximum": 74.34, "minimum": 74.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 74.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3000", "type": "HCPCS" } ], "description": "Ft insert ucb berkeley shell", "standard_charges": [ { "billing_class": "facility", "maximum": 386.06, "minimum": 386.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 386.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3001", "type": "HCPCS" } ], "description": "Foot insert remov molded spe", "standard_charges": [ { "billing_class": "facility", "maximum": 162.56, "minimum": 162.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 162.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3002", "type": "HCPCS" } ], "description": "Foot insert plastazote or eq", "standard_charges": [ { "billing_class": "facility", "maximum": 198.48, "minimum": 198.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 198.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3003", "type": "HCPCS" } ], "description": "Foot insert silicone gel eac", "standard_charges": [ { "billing_class": "facility", "maximum": 214.11, "minimum": 214.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 214.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3010", "type": "HCPCS" } ], "description": "Foot longitudinal arch suppo", "standard_charges": [ { "billing_class": "facility", "maximum": 214.11, "minimum": 214.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 214.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3020", "type": "HCPCS" } ], "description": "Foot longitud/metatarsal sup", "standard_charges": [ { "billing_class": "facility", "maximum": 243.83, "minimum": 243.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 243.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3030", "type": "HCPCS" } ], "description": "Foot arch support remov prem", "standard_charges": [ { "billing_class": "facility", "maximum": 93.77, "minimum": 93.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3031", "type": "HCPCS" } ], "description": "Foot lamin/prepreg composite", "standard_charges": [ { "billing_class": "facility", "maximum": 150.51, "minimum": 150.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 150.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3040", "type": "HCPCS" } ], "description": "Ft arch suprt premold longit", "standard_charges": [ { "billing_class": "facility", "maximum": 57.84, "minimum": 57.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3050", "type": "HCPCS" } ], "description": "Foot arch supp premold metat", "standard_charges": [ { "billing_class": "facility", "maximum": 57.84, "minimum": 57.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3060", "type": "HCPCS" } ], "description": "Foot arch supp longitud/meta", "standard_charges": [ { "billing_class": "facility", "maximum": 90.65, "minimum": 90.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 90.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3070", "type": "HCPCS" } ], "description": "Arch suprt att to sho longit", "standard_charges": [ { "billing_class": "facility", "maximum": 39.08, "minimum": 39.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3080", "type": "HCPCS" } ], "description": "Arch supp att to shoe metata", "standard_charges": [ { "billing_class": "facility", "maximum": 39.08, "minimum": 39.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3090", "type": "HCPCS" } ], "description": "Arch supp att to shoe long/m", "standard_charges": [ { "billing_class": "facility", "maximum": 50.02, "minimum": 50.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3100", "type": "HCPCS" } ], "description": "Hallus-valgus nt dyn pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 53.16, "minimum": 53.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3140", "type": "HCPCS" } ], "description": "Abduction rotation bar shoe", "standard_charges": [ { "billing_class": "facility", "maximum": 109.41, "minimum": 109.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 109.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3150", "type": "HCPCS" } ], "description": "Abduct rotation bar w/o shoe", "standard_charges": [ { "billing_class": "facility", "maximum": 100.05, "minimum": 100.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3170", "type": "HCPCS" } ], "description": "Foot plas heel stabi pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 62.52, "minimum": 62.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3224", "type": "HCPCS" } ], "description": "Woman's shoe oxford brace", "standard_charges": [ { "billing_class": "facility", "maximum": 83.04, "minimum": 83.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 83.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3225", "type": "HCPCS" } ], "description": "Man's shoe oxford brace", "standard_charges": [ { "billing_class": "facility", "maximum": 90.7, "minimum": 90.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 90.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3300", "type": "HCPCS" } ], "description": "Sho lift taper to metatarsal", "standard_charges": [ { "billing_class": "facility", "maximum": 64.1, "minimum": 64.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 64.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3310", "type": "HCPCS" } ], "description": "Shoe lift elev heel/sole neo", "standard_charges": [ { "billing_class": "facility", "maximum": 100.05, "minimum": 100.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 100.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3330", "type": "HCPCS" } ], "description": "Lifts elevation metal extens", "standard_charges": [ { "billing_class": "facility", "maximum": 695.51, "minimum": 695.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 695.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3332", "type": "HCPCS" } ], "description": "Shoe lifts tapered to one-ha", "standard_charges": [ { "billing_class": "facility", "maximum": 90.65, "minimum": 90.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 90.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3334", "type": "HCPCS" } ], "description": "Shoe lifts elevation heel /i", "standard_charges": [ { "billing_class": "facility", "maximum": 46.87, "minimum": 46.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 46.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3340", "type": "HCPCS" } ], "description": "Shoe wedge sach", "standard_charges": [ { "billing_class": "facility", "maximum": 104.74, "minimum": 104.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 104.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3350", "type": "HCPCS" } ], "description": "Shoe heel wedge", "standard_charges": [ { "billing_class": "facility", "maximum": 28.11, "minimum": 28.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3360", "type": "HCPCS" } ], "description": "Shoe sole wedge outside sole", "standard_charges": [ { "billing_class": "facility", "maximum": 43.76, "minimum": 43.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 43.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3370", "type": "HCPCS" } ], "description": "Shoe sole wedge between sole", "standard_charges": [ { "billing_class": "facility", "maximum": 60.96, "minimum": 60.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3380", "type": "HCPCS" } ], "description": "Shoe clubfoot wedge", "standard_charges": [ { "billing_class": "facility", "maximum": 60.96, "minimum": 60.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3390", "type": "HCPCS" } ], "description": "Shoe outflare wedge", "standard_charges": [ { "billing_class": "facility", "maximum": 60.96, "minimum": 60.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3400", "type": "HCPCS" } ], "description": "Shoe metatarsal bar wedge ro", "standard_charges": [ { "billing_class": "facility", "maximum": 50.02, "minimum": 50.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3410", "type": "HCPCS" } ], "description": "Shoe metatarsal bar between", "standard_charges": [ { "billing_class": "facility", "maximum": 114.09, "minimum": 114.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3420", "type": "HCPCS" } ], "description": "Full sole/heel wedge btween", "standard_charges": [ { "billing_class": "facility", "maximum": 67.21, "minimum": 67.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 67.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3430", "type": "HCPCS" } ], "description": "Sho heel count plast reinfor", "standard_charges": [ { "billing_class": "facility", "maximum": 196.94, "minimum": 196.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 196.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3440", "type": "HCPCS" } ], "description": "Heel leather reinforced", "standard_charges": [ { "billing_class": "facility", "maximum": 93.77, "minimum": 93.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3450", "type": "HCPCS" } ], "description": "Shoe heel sach cushion type", "standard_charges": [ { "billing_class": "facility", "maximum": 129.69, "minimum": 129.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3455", "type": "HCPCS" } ], "description": "Shoe heel new leather standa", "standard_charges": [ { "billing_class": "facility", "maximum": 50.02, "minimum": 50.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 50.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3460", "type": "HCPCS" } ], "description": "Shoe heel new rubber standar", "standard_charges": [ { "billing_class": "facility", "maximum": 42.22, "minimum": 42.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 42.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3465", "type": "HCPCS" } ], "description": "Shoe heel thomas with wedge", "standard_charges": [ { "billing_class": "facility", "maximum": 71.94, "minimum": 71.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 71.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3470", "type": "HCPCS" } ], "description": "Shoe heel thomas extend to b", "standard_charges": [ { "billing_class": "facility", "maximum": 76.57, "minimum": 76.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 76.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3480", "type": "HCPCS" } ], "description": "Shoe heel pad & depress for", "standard_charges": [ { "billing_class": "facility", "maximum": 76.57, "minimum": 76.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 76.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3500", "type": "HCPCS" } ], "description": "Ortho shoe add leather insol", "standard_charges": [ { "billing_class": "facility", "maximum": 35.93, "minimum": 35.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3510", "type": "HCPCS" } ], "description": "Orthopedic shoe add rub insl", "standard_charges": [ { "billing_class": "facility", "maximum": 35.93, "minimum": 35.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 35.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3520", "type": "HCPCS" } ], "description": "O shoe add felt w leath insl", "standard_charges": [ { "billing_class": "facility", "maximum": 39.08, "minimum": 39.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3530", "type": "HCPCS" } ], "description": "Ortho shoe add half sole", "standard_charges": [ { "billing_class": "facility", "maximum": 39.08, "minimum": 39.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3540", "type": "HCPCS" } ], "description": "Ortho shoe add full sole", "standard_charges": [ { "billing_class": "facility", "maximum": 62.52, "minimum": 62.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 62.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3550", "type": "HCPCS" } ], "description": "O shoe add standard toe tap", "standard_charges": [ { "billing_class": "facility", "maximum": 10.99, "minimum": 10.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3560", "type": "HCPCS" } ], "description": "O shoe add horseshoe toe tap", "standard_charges": [ { "billing_class": "facility", "maximum": 28.11, "minimum": 28.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3570", "type": "HCPCS" } ], "description": "O shoe add instep extension", "standard_charges": [ { "billing_class": "facility", "maximum": 104.74, "minimum": 104.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 104.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3580", "type": "HCPCS" } ], "description": "O shoe add instep velcro clo", "standard_charges": [ { "billing_class": "facility", "maximum": 79.7, "minimum": 79.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3590", "type": "HCPCS" } ], "description": "O shoe convert to sof counte", "standard_charges": [ { "billing_class": "facility", "maximum": 65.66, "minimum": 65.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 65.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3595", "type": "HCPCS" } ], "description": "Ortho shoe add march bar", "standard_charges": [ { "billing_class": "facility", "maximum": 51.54, "minimum": 51.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3600", "type": "HCPCS" } ], "description": "Trans shoe calip plate exist", "standard_charges": [ { "billing_class": "facility", "maximum": 93.77, "minimum": 93.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3610", "type": "HCPCS" } ], "description": "Trans shoe caliper plate new", "standard_charges": [ { "billing_class": "facility", "maximum": 123.48, "minimum": 123.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 123.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3620", "type": "HCPCS" } ], "description": "Trans shoe solid stirrup exi", "standard_charges": [ { "billing_class": "facility", "maximum": 93.77, "minimum": 93.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 93.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3630", "type": "HCPCS" } ], "description": "Trans shoe solid stirrup new", "standard_charges": [ { "billing_class": "facility", "maximum": 123.48, "minimum": 123.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 123.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3640", "type": "HCPCS" } ], "description": "Shoe dennis browne splint bo", "standard_charges": [ { "billing_class": "facility", "maximum": 53.16, "minimum": 53.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 53.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3650", "type": "HCPCS" } ], "description": "So 8 abd restraint pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 80.6, "minimum": 80.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 80.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3660", "type": "HCPCS" } ], "description": "So 8 ab rstr can/web pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 115.57, "minimum": 115.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 115.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3670", "type": "HCPCS" } ], "description": "So acro/clav can web pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 127.15, "minimum": 127.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 127.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3671", "type": "HCPCS" } ], "description": "SO cap design w/o jnts CF", "standard_charges": [ { "billing_class": "facility", "maximum": 1007.79, "minimum": 1007.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1007.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3674", "type": "HCPCS" } ], "description": "SO airplane w/wo joint CF", "standard_charges": [ { "billing_class": "facility", "maximum": 1322.06, "minimum": 1322.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1322.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3675", "type": "HCPCS" } ], "description": "So vest canvas/web pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 196.31, "minimum": 196.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 196.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3702", "type": "HCPCS" } ], "description": "EO w/o joints CF", "standard_charges": [ { "billing_class": "facility", "maximum": 322.97, "minimum": 322.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 322.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3710", "type": "HCPCS" } ], "description": "Eo elas w/metal jnts pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 159.7, "minimum": 159.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 159.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3720", "type": "HCPCS" } ], "description": "Forearm/arm cuffs free motio", "standard_charges": [ { "billing_class": "facility", "maximum": 764.22, "minimum": 764.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 764.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3730", "type": "HCPCS" } ], "description": "Forearm/arm cuffs ext/flex a", "standard_charges": [ { "billing_class": "facility", "maximum": 1013.66, "minimum": 1013.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1013.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3740", "type": "HCPCS" } ], "description": "Cuffs adj lock w/ active con", "standard_charges": [ { "billing_class": "facility", "maximum": 1201.78, "minimum": 1201.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1201.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3760", "type": "HCPCS" } ], "description": "EO withjoint, Prefabricated", "standard_charges": [ { "billing_class": "facility", "maximum": 559.36, "minimum": 559.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 559.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3761", "type": "HCPCS" } ], "description": "Eo, adj lock joint prefab ot", "standard_charges": [ { "billing_class": "facility", "maximum": 559.36, "minimum": 559.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 559.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3762", "type": "HCPCS" } ], "description": "Eo rigid w/o joints pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 120.25, "minimum": 120.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 120.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3763", "type": "HCPCS" } ], "description": "EWHO rigid w/o jnts CF", "standard_charges": [ { "billing_class": "facility", "maximum": 836.99, "minimum": 836.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 836.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3764", "type": "HCPCS" } ], "description": "EWHO w/joint(s) CF", "standard_charges": [ { "billing_class": "facility", "maximum": 875.94, "minimum": 875.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 875.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3765", "type": "HCPCS" } ], "description": "EWHFO rigid w/o jnts CF", "standard_charges": [ { "billing_class": "facility", "maximum": 1434.15, "minimum": 1434.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1434.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3766", "type": "HCPCS" } ], "description": "EWHFO w/joint(s) CF", "standard_charges": [ { "billing_class": "facility", "maximum": 1518.68, "minimum": 1518.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1518.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3806", "type": "HCPCS" } ], "description": "WHFO w/joint(s) custom fab", "standard_charges": [ { "billing_class": "facility", "maximum": 508.03, "minimum": 508.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 508.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3807", "type": "HCPCS" } ], "description": "Whfo w/o joints pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 279.67, "minimum": 279.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 279.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3808", "type": "HCPCS" } ], "description": "WHFO, rigid w/o joints", "standard_charges": [ { "billing_class": "facility", "maximum": 398.43, "minimum": 398.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 398.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3809", "type": "HCPCS" } ], "description": "Whfo w/o joints pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 279.67, "minimum": 279.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 279.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3900", "type": "HCPCS" } ], "description": "Hinge extension/flex wrist/f", "standard_charges": [ { "billing_class": "facility", "maximum": 1811.85, "minimum": 1811.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1811.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3901", "type": "HCPCS" } ], "description": "Hinge ext/flex wrist finger", "standard_charges": [ { "billing_class": "facility", "maximum": 2374.53, "minimum": 2374.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2374.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3904", "type": "HCPCS" } ], "description": "Whfo electric custom fitted", "standard_charges": [ { "billing_class": "facility", "maximum": 3775.23, "minimum": 3775.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3775.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3905", "type": "HCPCS" } ], "description": "Who w/nontorsion jnt(s) cf", "standard_charges": [ { "billing_class": "facility", "maximum": 1109.16, "minimum": 1109.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1109.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3906", "type": "HCPCS" } ], "description": "Who w/o joints cf", "standard_charges": [ { "billing_class": "facility", "maximum": 566.79, "minimum": 566.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 566.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3908", "type": "HCPCS" } ], "description": "Who cock-up nonmolde pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 82.0, "minimum": 82.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 82.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3912", "type": "HCPCS" } ], "description": "Hfo flexion glove pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 117.84, "minimum": 117.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 117.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3913", "type": "HCPCS" } ], "description": "HFO w/o joints CF", "standard_charges": [ { "billing_class": "facility", "maximum": 302.9, "minimum": 302.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 302.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3915", "type": "HCPCS" } ], "description": "Who nontorsion jnts pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 594.54, "minimum": 594.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 594.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3916", "type": "HCPCS" } ], "description": "Who nontorsion jnts pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 594.54, "minimum": 594.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 594.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3917", "type": "HCPCS" } ], "description": "Metacarp fx orthosis pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 118.11, "minimum": 118.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 118.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3918", "type": "HCPCS" } ], "description": "Metacarp fx orthosis pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 118.11, "minimum": 118.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 118.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3919", "type": "HCPCS" } ], "description": "HO w/o joints CF", "standard_charges": [ { "billing_class": "facility", "maximum": 302.9, "minimum": 302.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 302.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3921", "type": "HCPCS" } ], "description": "HFO w/joint(s) CF", "standard_charges": [ { "billing_class": "facility", "maximum": 359.28, "minimum": 359.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 359.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3923", "type": "HCPCS" } ], "description": "Hfo without joints pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 108.04, "minimum": 108.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3924", "type": "HCPCS" } ], "description": "Hfo without joints pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 108.04, "minimum": 108.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 108.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3925", "type": "HCPCS" } ], "description": "Fo pip dip jnt/sprng pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 73.47, "minimum": 73.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3927", "type": "HCPCS" } ], "description": "Fo pip dip no jt spr pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 39.15, "minimum": 39.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3929", "type": "HCPCS" } ], "description": "Hfo nontorsion jnts pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 102.16, "minimum": 102.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 102.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3930", "type": "HCPCS" } ], "description": "Hfo nontorsion jnts pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 102.16, "minimum": 102.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 102.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3931", "type": "HCPCS" } ], "description": "WHFO nontorsion joint prefab", "standard_charges": [ { "billing_class": "facility", "maximum": 233.2, "minimum": 233.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 233.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3933", "type": "HCPCS" } ], "description": "FO w/o joints CF", "standard_charges": [ { "billing_class": "facility", "maximum": 238.64, "minimum": 238.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 238.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3935", "type": "HCPCS" } ], "description": "FO nontorsion joint CF", "standard_charges": [ { "billing_class": "facility", "maximum": 247.07, "minimum": 247.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 247.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3960", "type": "HCPCS" } ], "description": "Sewho airplan desig abdu pos", "standard_charges": [ { "billing_class": "facility", "maximum": 892.05, "minimum": 892.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 892.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3961", "type": "HCPCS" } ], "description": "Sewho cap design w/o jnts cf", "standard_charges": [ { "billing_class": "facility", "maximum": 1879.17, "minimum": 1879.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1879.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3962", "type": "HCPCS" } ], "description": "Sewho erbs palsey design abd", "standard_charges": [ { "billing_class": "facility", "maximum": 806.8, "minimum": 806.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 806.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3967", "type": "HCPCS" } ], "description": "Sewho airplane w/o jnts cf", "standard_charges": [ { "billing_class": "facility", "maximum": 2218.63, "minimum": 2218.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2218.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3971", "type": "HCPCS" } ], "description": "Sewho cap design w/jnt(s) cf", "standard_charges": [ { "billing_class": "facility", "maximum": 2106.0, "minimum": 2106.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2106.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3973", "type": "HCPCS" } ], "description": "Sewho airplane w/jnt(s) cf", "standard_charges": [ { "billing_class": "facility", "maximum": 2218.63, "minimum": 2218.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2218.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3975", "type": "HCPCS" } ], "description": "Sewhfo cap design w/o jnt cf", "standard_charges": [ { "billing_class": "facility", "maximum": 1879.17, "minimum": 1879.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1879.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3976", "type": "HCPCS" } ], "description": "Sewhfo airplane w/o jnts cf", "standard_charges": [ { "billing_class": "facility", "maximum": 1879.17, "minimum": 1879.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1879.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3977", "type": "HCPCS" } ], "description": "Sewhfo cap desgn w/jnt(s) cf", "standard_charges": [ { "billing_class": "facility", "maximum": 2106.0, "minimum": 2106.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2106.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3978", "type": "HCPCS" } ], "description": "Sewhfo airplane w/jnt(s) cf", "standard_charges": [ { "billing_class": "facility", "maximum": 2218.63, "minimum": 2218.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2218.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3980", "type": "HCPCS" } ], "description": "Up ext fx orthos humeral nos", "standard_charges": [ { "billing_class": "facility", "maximum": 432.69, "minimum": 432.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 432.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3981", "type": "HCPCS" } ], "description": "Ue fx orth shoul cap forearm", "standard_charges": [ { "billing_class": "facility", "maximum": 1125.8, "minimum": 1125.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1125.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3982", "type": "HCPCS" } ], "description": "Upper ext fx orthosis rad/ul", "standard_charges": [ { "billing_class": "facility", "maximum": 439.35, "minimum": 439.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 439.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3984", "type": "HCPCS" } ], "description": "Upper ext fx orthosis wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 387.03, "minimum": 387.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 387.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L3995", "type": "HCPCS" } ], "description": "Sock fracture or equal each", "standard_charges": [ { "billing_class": "facility", "maximum": 45.92, "minimum": 45.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 45.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4000", "type": "HCPCS" } ], "description": "Repl girdle milwaukee orth", "standard_charges": [ { "billing_class": "facility", "maximum": 1623.97, "minimum": 1623.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1623.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4010", "type": "HCPCS" } ], "description": "Replace trilateral socket br", "standard_charges": [ { "billing_class": "facility", "maximum": 987.07, "minimum": 987.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 987.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4020", "type": "HCPCS" } ], "description": "Replace quadlat socket brim", "standard_charges": [ { "billing_class": "facility", "maximum": 1185.74, "minimum": 1185.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1185.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4030", "type": "HCPCS" } ], "description": "Replace socket brim cust fit", "standard_charges": [ { "billing_class": "facility", "maximum": 753.5, "minimum": 753.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 753.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4040", "type": "HCPCS" } ], "description": "Replace molded thigh lacer", "standard_charges": [ { "billing_class": "facility", "maximum": 510.29, "minimum": 510.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 510.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4045", "type": "HCPCS" } ], "description": "Replace non-molded thigh lac", "standard_charges": [ { "billing_class": "facility", "maximum": 376.94, "minimum": 376.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 376.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4050", "type": "HCPCS" } ], "description": "Replace molded calf lacer", "standard_charges": [ { "billing_class": "facility", "maximum": 505.37, "minimum": 505.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 505.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4055", "type": "HCPCS" } ], "description": "Replace non-molded calf lace", "standard_charges": [ { "billing_class": "facility", "maximum": 307.2, "minimum": 307.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 307.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4060", "type": "HCPCS" } ], "description": "Replace high roll cuff", "standard_charges": [ { "billing_class": "facility", "maximum": 399.32, "minimum": 399.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 399.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4070", "type": "HCPCS" } ], "description": "Replace prox & dist upright", "standard_charges": [ { "billing_class": "facility", "maximum": 323.39, "minimum": 323.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 323.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4080", "type": "HCPCS" } ], "description": "Repl met band kafo-afo prox", "standard_charges": [ { "billing_class": "facility", "maximum": 122.09, "minimum": 122.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 122.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4090", "type": "HCPCS" } ], "description": "Repl met band kafo-afo calf/", "standard_charges": [ { "billing_class": "facility", "maximum": 103.88, "minimum": 103.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 103.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4100", "type": "HCPCS" } ], "description": "Repl leath cuff kafo prox th", "standard_charges": [ { "billing_class": "facility", "maximum": 124.81, "minimum": 124.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 124.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4110", "type": "HCPCS" } ], "description": "Repl leath cuff kafo-afo cal", "standard_charges": [ { "billing_class": "facility", "maximum": 97.45, "minimum": 97.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 97.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4130", "type": "HCPCS" } ], "description": "Replace pretibial shell", "standard_charges": [ { "billing_class": "facility", "maximum": 589.05, "minimum": 589.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 589.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4205", "type": "HCPCS" } ], "description": "Ortho dvc repair per 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 29.92, "minimum": 29.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4350", "type": "HCPCS" } ], "description": "Ankle control ortho pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 118.9, "minimum": 118.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 118.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4360", "type": "HCPCS" } ], "description": "Pneumat walking boot pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 318.18, "minimum": 318.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4361", "type": "HCPCS" } ], "description": "Pneuma/vac walk boot pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 318.18, "minimum": 318.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 318.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4370", "type": "HCPCS" } ], "description": "Pneum full leg splnt pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 289.25, "minimum": 289.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 289.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4386", "type": "HCPCS" } ], "description": "Non-pneum walk boot pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 194.86, "minimum": 194.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4387", "type": "HCPCS" } ], "description": "Non-pneum walk boot pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 194.86, "minimum": 194.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 194.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4392", "type": "HCPCS" } ], "description": "Replace AFO soft interface", "standard_charges": [ { "billing_class": "facility", "maximum": 28.91, "minimum": 28.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4394", "type": "HCPCS" } ], "description": "Replace foot drop spint", "standard_charges": [ { "billing_class": "facility", "maximum": 21.09, "minimum": 21.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4396", "type": "HCPCS" } ], "description": "Static or dynami afo pre cst", "standard_charges": [ { "billing_class": "facility", "maximum": 206.23, "minimum": 206.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 206.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4397", "type": "HCPCS" } ], "description": "Static or dynami afo pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 206.23, "minimum": 206.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 206.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4398", "type": "HCPCS" } ], "description": "Foot drop splint pre ots", "standard_charges": [ { "billing_class": "facility", "maximum": 94.92, "minimum": 94.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L4631", "type": "HCPCS" } ], "description": "Afo, walk boot type, cus fab", "standard_charges": [ { "billing_class": "facility", "maximum": 1811.67, "minimum": 1811.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1811.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5000", "type": "HCPCS" } ], "description": "Sho insert w arch toe filler", "standard_charges": [ { "billing_class": "facility", "maximum": 705.71, "minimum": 705.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 705.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5010", "type": "HCPCS" } ], "description": "Mold socket ank hgt w/ toe f", "standard_charges": [ { "billing_class": "facility", "maximum": 1971.82, "minimum": 1971.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1971.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5020", "type": "HCPCS" } ], "description": "Tibial tubercle hgt w/ toe f", "standard_charges": [ { "billing_class": "facility", "maximum": 3089.2, "minimum": 3089.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3089.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5050", "type": "HCPCS" } ], "description": "Ank symes mold sckt sach ft", "standard_charges": [ { "billing_class": "facility", "maximum": 3374.0, "minimum": 3374.0, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3374.0 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5060", "type": "HCPCS" } ], "description": "Symes met fr leath socket ar", "standard_charges": [ { "billing_class": "facility", "maximum": 4159.16, "minimum": 4159.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4159.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5100", "type": "HCPCS" } ], "description": "Molded socket shin sach foot", "standard_charges": [ { "billing_class": "facility", "maximum": 3359.56, "minimum": 3359.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3359.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5105", "type": "HCPCS" } ], "description": "Plast socket jts/thgh lacer", "standard_charges": [ { "billing_class": "facility", "maximum": 4741.07, "minimum": 4741.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4741.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5150", "type": "HCPCS" } ], "description": "Mold sckt ext knee shin sach", "standard_charges": [ { "billing_class": "facility", "maximum": 5270.94, "minimum": 5270.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5270.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5160", "type": "HCPCS" } ], "description": "Mold socket bent knee shin s", "standard_charges": [ { "billing_class": "facility", "maximum": 5787.25, "minimum": 5787.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5787.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5200", "type": "HCPCS" } ], "description": "Kne sing axis fric shin sach", "standard_charges": [ { "billing_class": "facility", "maximum": 4476.02, "minimum": 4476.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4476.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5210", "type": "HCPCS" } ], "description": "No knee/ankle joints w/ ft b", "standard_charges": [ { "billing_class": "facility", "maximum": 3553.95, "minimum": 3553.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3553.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5220", "type": "HCPCS" } ], "description": "No knee joint with artic ali", "standard_charges": [ { "billing_class": "facility", "maximum": 3914.91, "minimum": 3914.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3914.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5230", "type": "HCPCS" } ], "description": "Fem focal defic constant fri", "standard_charges": [ { "billing_class": "facility", "maximum": 5871.76, "minimum": 5871.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5871.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5250", "type": "HCPCS" } ], "description": "Hip canad sing axi cons fric", "standard_charges": [ { "billing_class": "facility", "maximum": 6884.81, "minimum": 6884.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6884.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5270", "type": "HCPCS" } ], "description": "Tilt table locking hip sing", "standard_charges": [ { "billing_class": "facility", "maximum": 7671.01, "minimum": 7671.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7671.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5280", "type": "HCPCS" } ], "description": "Hemipelvect canad sing axis", "standard_charges": [ { "billing_class": "facility", "maximum": 7456.53, "minimum": 7456.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7456.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5301", "type": "HCPCS" } ], "description": "Bk mold socket sach ft endo", "standard_charges": [ { "billing_class": "facility", "maximum": 3299.01, "minimum": 3299.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3299.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5312", "type": "HCPCS" } ], "description": "Knee disart, SACH ft, endo", "standard_charges": [ { "billing_class": "facility", "maximum": 5197.83, "minimum": 5197.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5197.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5321", "type": "HCPCS" } ], "description": "Ak open end sach", "standard_charges": [ { "billing_class": "facility", "maximum": 4399.13, "minimum": 4399.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4399.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5331", "type": "HCPCS" } ], "description": "Hip disart canadian sach ft", "standard_charges": [ { "billing_class": "facility", "maximum": 6443.12, "minimum": 6443.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6443.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5341", "type": "HCPCS" } ], "description": "Hemipelvectomy canadian sach", "standard_charges": [ { "billing_class": "facility", "maximum": 6848.94, "minimum": 6848.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6848.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5400", "type": "HCPCS" } ], "description": "Postop dress & 1 cast chg bk", "standard_charges": [ { "billing_class": "facility", "maximum": 1964.57, "minimum": 1964.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1964.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5410", "type": "HCPCS" } ], "description": "Postop dsg bk ea add cast ch", "standard_charges": [ { "billing_class": "facility", "maximum": 542.75, "minimum": 542.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 542.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5420", "type": "HCPCS" } ], "description": "Postop dsg & 1 cast chg ak/d", "standard_charges": [ { "billing_class": "facility", "maximum": 2481.17, "minimum": 2481.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2481.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5430", "type": "HCPCS" } ], "description": "Postop dsg ak ea add cast ch", "standard_charges": [ { "billing_class": "facility", "maximum": 673.51, "minimum": 673.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 673.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5450", "type": "HCPCS" } ], "description": "Postop app non-wgt bear dsg", "standard_charges": [ { "billing_class": "facility", "maximum": 582.35, "minimum": 582.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 582.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5460", "type": "HCPCS" } ], "description": "Postop app non-wgt bear dsg", "standard_charges": [ { "billing_class": "facility", "maximum": 763.82, "minimum": 763.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 763.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5500", "type": "HCPCS" } ], "description": "Init bk ptb plaster direct", "standard_charges": [ { "billing_class": "facility", "maximum": 1815.83, "minimum": 1815.83, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1815.83 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5505", "type": "HCPCS" } ], "description": "Init ak ischal plstr direct", "standard_charges": [ { "billing_class": "facility", "maximum": 2554.38, "minimum": 2554.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2554.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5510", "type": "HCPCS" } ], "description": "Prep BK ptb plaster molded", "standard_charges": [ { "billing_class": "facility", "maximum": 2168.42, "minimum": 2168.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2168.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5520", "type": "HCPCS" } ], "description": "Perp BK ptb thermopls direct", "standard_charges": [ { "billing_class": "facility", "maximum": 1943.72, "minimum": 1943.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1943.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5530", "type": "HCPCS" } ], "description": "Prep BK ptb thermopls molded", "standard_charges": [ { "billing_class": "facility", "maximum": 2555.15, "minimum": 2555.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2555.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5535", "type": "HCPCS" } ], "description": "Prep BK ptb open end socket", "standard_charges": [ { "billing_class": "facility", "maximum": 2381.94, "minimum": 2381.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2381.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5540", "type": "HCPCS" } ], "description": "Prep BK ptb laminated socket", "standard_charges": [ { "billing_class": "facility", "maximum": 2522.82, "minimum": 2522.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2522.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5560", "type": "HCPCS" } ], "description": "Prep AK ischial plast molded", "standard_charges": [ { "billing_class": "facility", "maximum": 2874.62, "minimum": 2874.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2874.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5570", "type": "HCPCS" } ], "description": "Prep AK ischial direct form", "standard_charges": [ { "billing_class": "facility", "maximum": 2789.92, "minimum": 2789.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2789.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5580", "type": "HCPCS" } ], "description": "Prep AK ischial thermo mold", "standard_charges": [ { "billing_class": "facility", "maximum": 3462.71, "minimum": 3462.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3462.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5585", "type": "HCPCS" } ], "description": "Prep AK ischial open end", "standard_charges": [ { "billing_class": "facility", "maximum": 4055.09, "minimum": 4055.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4055.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5590", "type": "HCPCS" } ], "description": "Prep AK ischial laminated", "standard_charges": [ { "billing_class": "facility", "maximum": 3610.21, "minimum": 3610.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3610.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5595", "type": "HCPCS" } ], "description": "Hip disartic sach thermopls", "standard_charges": [ { "billing_class": "facility", "maximum": 5641.82, "minimum": 5641.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5641.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5600", "type": "HCPCS" } ], "description": "Hip disart sach laminat mold", "standard_charges": [ { "billing_class": "facility", "maximum": 6421.23, "minimum": 6421.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6421.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5610", "type": "HCPCS" } ], "description": "Above knee hydracadence", "standard_charges": [ { "billing_class": "facility", "maximum": 3096.92, "minimum": 3096.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3096.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5611", "type": "HCPCS" } ], "description": "Ak 4 bar link w/fric swing", "standard_charges": [ { "billing_class": "facility", "maximum": 1972.47, "minimum": 1972.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1972.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5613", "type": "HCPCS" } ], "description": "Ak 4 bar ling w/hydraul swig", "standard_charges": [ { "billing_class": "facility", "maximum": 3000.26, "minimum": 3000.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3000.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5614", "type": "HCPCS" } ], "description": "4-bar link above knee w/swng", "standard_charges": [ { "billing_class": "facility", "maximum": 2077.88, "minimum": 2077.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2077.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5615", "type": "HCPCS" } ], "description": "Ak 4 bar link hydl swg/stanc", "standard_charges": [ { "billing_class": "facility", "maximum": 6927.99, "minimum": 6927.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6927.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5616", "type": "HCPCS" } ], "description": "Ak univ multiplex sys frict", "standard_charges": [ { "billing_class": "facility", "maximum": 1809.06, "minimum": 1809.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1809.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5617", "type": "HCPCS" } ], "description": "AK/BK self-aligning unit ea", "standard_charges": [ { "billing_class": "facility", "maximum": 688.96, "minimum": 688.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 688.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5618", "type": "HCPCS" } ], "description": "Test socket symes", "standard_charges": [ { "billing_class": "facility", "maximum": 411.43, "minimum": 411.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 411.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5620", "type": "HCPCS" } ], "description": "Test socket below knee", "standard_charges": [ { "billing_class": "facility", "maximum": 365.04, "minimum": 365.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 365.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5622", "type": "HCPCS" } ], "description": "Test socket knee disarticula", "standard_charges": [ { "billing_class": "facility", "maximum": 491.79, "minimum": 491.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 491.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5624", "type": "HCPCS" } ], "description": "Test socket above knee", "standard_charges": [ { "billing_class": "facility", "maximum": 491.61, "minimum": 491.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 491.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5626", "type": "HCPCS" } ], "description": "Test socket hip disarticulat", "standard_charges": [ { "billing_class": "facility", "maximum": 778.27, "minimum": 778.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 778.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5628", "type": "HCPCS" } ], "description": "Test socket hemipelvectomy", "standard_charges": [ { "billing_class": "facility", "maximum": 788.11, "minimum": 788.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 788.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5629", "type": "HCPCS" } ], "description": "Below knee acrylic socket", "standard_charges": [ { "billing_class": "facility", "maximum": 389.06, "minimum": 389.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 389.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5630", "type": "HCPCS" } ], "description": "Syme typ expandabl wall sckt", "standard_charges": [ { "billing_class": "facility", "maximum": 676.01, "minimum": 676.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 676.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5631", "type": "HCPCS" } ], "description": "Ak/knee disartic acrylic soc", "standard_charges": [ { "billing_class": "facility", "maximum": 537.91, "minimum": 537.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 537.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5632", "type": "HCPCS" } ], "description": "Symes type ptb brim design s", "standard_charges": [ { "billing_class": "facility", "maximum": 331.54, "minimum": 331.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 331.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5634", "type": "HCPCS" } ], "description": "Symes type poster opening so", "standard_charges": [ { "billing_class": "facility", "maximum": 414.62, "minimum": 414.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 414.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5636", "type": "HCPCS" } ], "description": "Symes type medial opening so", "standard_charges": [ { "billing_class": "facility", "maximum": 316.91, "minimum": 316.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 316.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5637", "type": "HCPCS" } ], "description": "Below knee total contact", "standard_charges": [ { "billing_class": "facility", "maximum": 471.56, "minimum": 471.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 471.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5638", "type": "HCPCS" } ], "description": "Below knee leather socket", "standard_charges": [ { "billing_class": "facility", "maximum": 794.39, "minimum": 794.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 794.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5639", "type": "HCPCS" } ], "description": "Below knee wood socket", "standard_charges": [ { "billing_class": "facility", "maximum": 1372.6, "minimum": 1372.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1372.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5640", "type": "HCPCS" } ], "description": "Knee disarticulat leather so", "standard_charges": [ { "billing_class": "facility", "maximum": 902.21, "minimum": 902.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 902.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5642", "type": "HCPCS" } ], "description": "Above knee leather socket", "standard_charges": [ { "billing_class": "facility", "maximum": 836.32, "minimum": 836.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 836.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5643", "type": "HCPCS" } ], "description": "Hip flex inner socket ext fr", "standard_charges": [ { "billing_class": "facility", "maximum": 2466.73, "minimum": 2466.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2466.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5644", "type": "HCPCS" } ], "description": "Above knee wood socket", "standard_charges": [ { "billing_class": "facility", "maximum": 723.09, "minimum": 723.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 723.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5645", "type": "HCPCS" } ], "description": "Bk flex inner socket ext fra", "standard_charges": [ { "billing_class": "facility", "maximum": 1199.56, "minimum": 1199.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1199.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5646", "type": "HCPCS" } ], "description": "Below knee cushion socket", "standard_charges": [ { "billing_class": "facility", "maximum": 760.2, "minimum": 760.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 760.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5647", "type": "HCPCS" } ], "description": "Below knee suction socket", "standard_charges": [ { "billing_class": "facility", "maximum": 973.84, "minimum": 973.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 973.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5648", "type": "HCPCS" } ], "description": "Above knee cushion socket", "standard_charges": [ { "billing_class": "facility", "maximum": 898.23, "minimum": 898.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 898.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5649", "type": "HCPCS" } ], "description": "Isch containmt/narrow m-l so", "standard_charges": [ { "billing_class": "facility", "maximum": 3018.14, "minimum": 3018.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3018.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5650", "type": "HCPCS" } ], "description": "Tot contact ak/knee disart s", "standard_charges": [ { "billing_class": "facility", "maximum": 597.66, "minimum": 597.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 597.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5651", "type": "HCPCS" } ], "description": "Ak flex inner socket ext fra", "standard_charges": [ { "billing_class": "facility", "maximum": 1751.06, "minimum": 1751.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1751.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5652", "type": "HCPCS" } ], "description": "Suction susp ak/knee disart", "standard_charges": [ { "billing_class": "facility", "maximum": 533.75, "minimum": 533.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 533.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5653", "type": "HCPCS" } ], "description": "Knee disart expand wall sock", "standard_charges": [ { "billing_class": "facility", "maximum": 832.81, "minimum": 832.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 832.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5654", "type": "HCPCS" } ], "description": "Socket insert symes", "standard_charges": [ { "billing_class": "facility", "maximum": 482.77, "minimum": 482.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 482.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5655", "type": "HCPCS" } ], "description": "Socket insert below knee", "standard_charges": [ { "billing_class": "facility", "maximum": 348.56, "minimum": 348.56, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 348.56 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5656", "type": "HCPCS" } ], "description": "Socket insert knee articulat", "standard_charges": [ { "billing_class": "facility", "maximum": 529.54, "minimum": 529.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 529.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5658", "type": "HCPCS" } ], "description": "Socket insert above knee", "standard_charges": [ { "billing_class": "facility", "maximum": 558.94, "minimum": 558.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 558.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5661", "type": "HCPCS" } ], "description": "Multi-durometer symes", "standard_charges": [ { "billing_class": "facility", "maximum": 801.96, "minimum": 801.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 801.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5665", "type": "HCPCS" } ], "description": "Multi-durometer below knee", "standard_charges": [ { "billing_class": "facility", "maximum": 712.97, "minimum": 712.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 712.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5666", "type": "HCPCS" } ], "description": "Below knee cuff suspension", "standard_charges": [ { "billing_class": "facility", "maximum": 94.4, "minimum": 94.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5668", "type": "HCPCS" } ], "description": "Bk molded distal cushion", "standard_charges": [ { "billing_class": "facility", "maximum": 140.62, "minimum": 140.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 140.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5670", "type": "HCPCS" } ], "description": "Bk molded supracondylar susp", "standard_charges": [ { "billing_class": "facility", "maximum": 332.2, "minimum": 332.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 332.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5671", "type": "HCPCS" } ], "description": "Bk/ak locking mechanism", "standard_charges": [ { "billing_class": "facility", "maximum": 608.96, "minimum": 608.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5672", "type": "HCPCS" } ], "description": "Bk removable medial brim sus", "standard_charges": [ { "billing_class": "facility", "maximum": 439.6, "minimum": 439.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 439.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5673", "type": "HCPCS" } ], "description": "Socket insert w lock mech", "standard_charges": [ { "billing_class": "facility", "maximum": 967.82, "minimum": 967.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 967.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5676", "type": "HCPCS" } ], "description": "Bk knee joints single axis p", "standard_charges": [ { "billing_class": "facility", "maximum": 443.63, "minimum": 443.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 443.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5677", "type": "HCPCS" } ], "description": "Bk knee joints polycentric p", "standard_charges": [ { "billing_class": "facility", "maximum": 679.42, "minimum": 679.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 679.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5678", "type": "HCPCS" } ], "description": "Bk joint covers pair", "standard_charges": [ { "billing_class": "facility", "maximum": 48.61, "minimum": 48.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5679", "type": "HCPCS" } ], "description": "Socket insert w/o lock mech", "standard_charges": [ { "billing_class": "facility", "maximum": 806.49, "minimum": 806.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 806.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5680", "type": "HCPCS" } ], "description": "Bk thigh lacer non-molded", "standard_charges": [ { "billing_class": "facility", "maximum": 372.63, "minimum": 372.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 372.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5681", "type": "HCPCS" } ], "description": "Intl custm cong/latyp insert", "standard_charges": [ { "billing_class": "facility", "maximum": 1619.74, "minimum": 1619.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1619.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5682", "type": "HCPCS" } ], "description": "Bk thigh lacer glut/ischia m", "standard_charges": [ { "billing_class": "facility", "maximum": 765.63, "minimum": 765.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 765.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5683", "type": "HCPCS" } ], "description": "Initial custom socket insert", "standard_charges": [ { "billing_class": "facility", "maximum": 1619.74, "minimum": 1619.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1619.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5684", "type": "HCPCS" } ], "description": "Bk fork strap", "standard_charges": [ { "billing_class": "facility", "maximum": 58.93, "minimum": 58.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5685", "type": "HCPCS" } ], "description": "Below knee sus/seal sleeve", "standard_charges": [ { "billing_class": "facility", "maximum": 157.74, "minimum": 157.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 157.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5686", "type": "HCPCS" } ], "description": "Bk back check", "standard_charges": [ { "billing_class": "facility", "maximum": 70.87, "minimum": 70.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 70.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5688", "type": "HCPCS" } ], "description": "Bk waist belt webbing", "standard_charges": [ { "billing_class": "facility", "maximum": 75.28, "minimum": 75.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5690", "type": "HCPCS" } ], "description": "Bk waist belt padded and lin", "standard_charges": [ { "billing_class": "facility", "maximum": 153.65, "minimum": 153.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 153.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5692", "type": "HCPCS" } ], "description": "Ak pelvic control belt light", "standard_charges": [ { "billing_class": "facility", "maximum": 162.67, "minimum": 162.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 162.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5694", "type": "HCPCS" } ], "description": "Ak pelvic control belt pad/l", "standard_charges": [ { "billing_class": "facility", "maximum": 222.1, "minimum": 222.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 222.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5695", "type": "HCPCS" } ], "description": "Ak sleeve susp neoprene/equa", "standard_charges": [ { "billing_class": "facility", "maximum": 199.65, "minimum": 199.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 199.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5696", "type": "HCPCS" } ], "description": "Ak/knee disartic pelvic join", "standard_charges": [ { "billing_class": "facility", "maximum": 241.17, "minimum": 241.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 241.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5697", "type": "HCPCS" } ], "description": "Ak/knee disartic pelvic band", "standard_charges": [ { "billing_class": "facility", "maximum": 114.53, "minimum": 114.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 114.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5698", "type": "HCPCS" } ], "description": "Ak/knee disartic silesian ba", "standard_charges": [ { "billing_class": "facility", "maximum": 146.92, "minimum": 146.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 146.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5699", "type": "HCPCS" } ], "description": "Shoulder harness", "standard_charges": [ { "billing_class": "facility", "maximum": 251.1, "minimum": 251.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 251.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5700", "type": "HCPCS" } ], "description": "Replace socket below knee", "standard_charges": [ { "billing_class": "facility", "maximum": 3776.99, "minimum": 3776.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3776.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5701", "type": "HCPCS" } ], "description": "Replace socket above knee", "standard_charges": [ { "billing_class": "facility", "maximum": 4685.7, "minimum": 4685.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4685.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5702", "type": "HCPCS" } ], "description": "Replace socket hip", "standard_charges": [ { "billing_class": "facility", "maximum": 5905.61, "minimum": 5905.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5905.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5703", "type": "HCPCS" } ], "description": "Symes ankle w/o (sach) foot", "standard_charges": [ { "billing_class": "facility", "maximum": 3106.52, "minimum": 3106.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3106.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5704", "type": "HCPCS" } ], "description": "Custom shape cover bk", "standard_charges": [ { "billing_class": "facility", "maximum": 770.11, "minimum": 770.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 770.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5705", "type": "HCPCS" } ], "description": "Custom shape cover ak", "standard_charges": [ { "billing_class": "facility", "maximum": 1411.9, "minimum": 1411.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1411.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5706", "type": "HCPCS" } ], "description": "Custom shape cvr knee disart", "standard_charges": [ { "billing_class": "facility", "maximum": 1377.12, "minimum": 1377.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1377.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5707", "type": "HCPCS" } ], "description": "Custom shape cvr hip disart", "standard_charges": [ { "billing_class": "facility", "maximum": 1850.21, "minimum": 1850.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1850.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5710", "type": "HCPCS" } ], "description": "Kne-shin exo sng axi mnl loc", "standard_charges": [ { "billing_class": "facility", "maximum": 440.31, "minimum": 440.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 440.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5711", "type": "HCPCS" } ], "description": "Knee-shin exo mnl lock ultra", "standard_charges": [ { "billing_class": "facility", "maximum": 738.97, "minimum": 738.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 738.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5712", "type": "HCPCS" } ], "description": "Knee-shin exo frict swg & st", "standard_charges": [ { "billing_class": "facility", "maximum": 527.52, "minimum": 527.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 527.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5714", "type": "HCPCS" } ], "description": "Knee-shin exo variable frict", "standard_charges": [ { "billing_class": "facility", "maximum": 536.75, "minimum": 536.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 536.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5716", "type": "HCPCS" } ], "description": "Knee-shin exo mech stance ph", "standard_charges": [ { "billing_class": "facility", "maximum": 1061.36, "minimum": 1061.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1061.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5718", "type": "HCPCS" } ], "description": "Knee-shin exo frct swg & sta", "standard_charges": [ { "billing_class": "facility", "maximum": 1134.92, "minimum": 1134.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1134.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5722", "type": "HCPCS" } ], "description": "Knee-shin pneum swg frct exo", "standard_charges": [ { "billing_class": "facility", "maximum": 1380.15, "minimum": 1380.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1380.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5724", "type": "HCPCS" } ], "description": "Knee-shin exo fluid swing ph", "standard_charges": [ { "billing_class": "facility", "maximum": 2127.27, "minimum": 2127.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2127.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5726", "type": "HCPCS" } ], "description": "Knee-shin ext jnts fld swg e", "standard_charges": [ { "billing_class": "facility", "maximum": 2532.6, "minimum": 2532.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2532.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5728", "type": "HCPCS" } ], "description": "Knee-shin fluid swg & stance", "standard_charges": [ { "billing_class": "facility", "maximum": 2967.93, "minimum": 2967.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2967.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5780", "type": "HCPCS" } ], "description": "Knee-shin pneum/hydra pneum", "standard_charges": [ { "billing_class": "facility", "maximum": 1634.07, "minimum": 1634.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1634.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5781", "type": "HCPCS" } ], "description": "Lower limb pros vacuum pump", "standard_charges": [ { "billing_class": "facility", "maximum": 4926.9, "minimum": 4926.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4926.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5782", "type": "HCPCS" } ], "description": "HD low limb pros vacuum pump", "standard_charges": [ { "billing_class": "facility", "maximum": 5194.06, "minimum": 5194.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5194.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5783", "type": "HCPCS" } ], "description": "Add low ext mec limb vol sys", "standard_charges": [ { "billing_class": "facility", "maximum": 3150.07, "minimum": 3150.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3150.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5785", "type": "HCPCS" } ], "description": "Exoskeletal bk ultralt mater", "standard_charges": [ { "billing_class": "facility", "maximum": 636.06, "minimum": 636.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 636.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5790", "type": "HCPCS" } ], "description": "Exoskeletal ak ultra-light m", "standard_charges": [ { "billing_class": "facility", "maximum": 917.99, "minimum": 917.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 917.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5795", "type": "HCPCS" } ], "description": "Exoskel hip ultra-light mate", "standard_charges": [ { "billing_class": "facility", "maximum": 1314.46, "minimum": 1314.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1314.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5810", "type": "HCPCS" } ], "description": "Endoskel knee-shin mnl lock", "standard_charges": [ { "billing_class": "facility", "maximum": 700.33, "minimum": 700.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 700.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5811", "type": "HCPCS" } ], "description": "Endo knee-shin mnl lck ultra", "standard_charges": [ { "billing_class": "facility", "maximum": 966.47, "minimum": 966.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 966.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5812", "type": "HCPCS" } ], "description": "Endo knee-shin frct swg & st", "standard_charges": [ { "billing_class": "facility", "maximum": 727.31, "minimum": 727.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 727.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5814", "type": "HCPCS" } ], "description": "Endo knee-shin hydral swg ph", "standard_charges": [ { "billing_class": "facility", "maximum": 4573.12, "minimum": 4573.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4573.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5816", "type": "HCPCS" } ], "description": "Endo knee-shin polyc mch sta", "standard_charges": [ { "billing_class": "facility", "maximum": 1041.16, "minimum": 1041.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1041.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5818", "type": "HCPCS" } ], "description": "Endo knee-shin frct swg & st", "standard_charges": [ { "billing_class": "facility", "maximum": 1175.67, "minimum": 1175.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1175.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5822", "type": "HCPCS" } ], "description": "Endo knee-shin pneum swg frc", "standard_charges": [ { "billing_class": "facility", "maximum": 2156.75, "minimum": 2156.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2156.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5824", "type": "HCPCS" } ], "description": "Endo knee-shin fluid swing p", "standard_charges": [ { "billing_class": "facility", "maximum": 2038.76, "minimum": 2038.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2038.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5826", "type": "HCPCS" } ], "description": "Miniature knee joint", "standard_charges": [ { "billing_class": "facility", "maximum": 3845.42, "minimum": 3845.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3845.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5827", "type": "HCPCS" } ], "description": "Endo knee shin single axis", "standard_charges": [ { "billing_class": "facility", "maximum": 7159.66, "minimum": 7159.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7159.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5828", "type": "HCPCS" } ], "description": "Endo knee-shin fluid swg/sta", "standard_charges": [ { "billing_class": "facility", "maximum": 3628.49, "minimum": 3628.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3628.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5830", "type": "HCPCS" } ], "description": "Endo knee-shin pneum/swg pha", "standard_charges": [ { "billing_class": "facility", "maximum": 2446.57, "minimum": 2446.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2446.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5840", "type": "HCPCS" } ], "description": "Multi-axial knee/shin system", "standard_charges": [ { "billing_class": "facility", "maximum": 4801.96, "minimum": 4801.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4801.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5841", "type": "HCPCS" } ], "description": "Addition endoskletl knee-shi", "standard_charges": [ { "billing_class": "facility", "maximum": 2814.38, "minimum": 2814.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2814.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5845", "type": "HCPCS" } ], "description": "Knee-shin sys stance flexion", "standard_charges": [ { "billing_class": "facility", "maximum": 2207.05, "minimum": 2207.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2207.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5848", "type": "HCPCS" } ], "description": "Knee-shin sys hydraul stance", "standard_charges": [ { "billing_class": "facility", "maximum": 1324.12, "minimum": 1324.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1324.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5850", "type": "HCPCS" } ], "description": "Endo ak/hip knee extens assi", "standard_charges": [ { "billing_class": "facility", "maximum": 156.61, "minimum": 156.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 156.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5855", "type": "HCPCS" } ], "description": "Mech hip extension assist", "standard_charges": [ { "billing_class": "facility", "maximum": 378.09, "minimum": 378.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 378.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5856", "type": "HCPCS" } ], "description": "Elec knee-shin swing/stance", "standard_charges": [ { "billing_class": "facility", "maximum": 29559.78, "minimum": 29559.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29559.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5857", "type": "HCPCS" } ], "description": "Elec knee-shin swing only", "standard_charges": [ { "billing_class": "facility", "maximum": 10488.92, "minimum": 10488.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10488.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5858", "type": "HCPCS" } ], "description": "Stance phase only", "standard_charges": [ { "billing_class": "facility", "maximum": 22885.05, "minimum": 22885.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 22885.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5859", "type": "HCPCS" } ], "description": "Knee-shin pro flex/ext cont", "standard_charges": [ { "billing_class": "facility", "maximum": 17866.14, "minimum": 17866.14, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17866.14 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5910", "type": "HCPCS" } ], "description": "Endo below knee alignable sy", "standard_charges": [ { "billing_class": "facility", "maximum": 443.39, "minimum": 443.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 443.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5920", "type": "HCPCS" } ], "description": "Endo ak/hip alignable system", "standard_charges": [ { "billing_class": "facility", "maximum": 649.58, "minimum": 649.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 649.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5925", "type": "HCPCS" } ], "description": "Above knee manual lock", "standard_charges": [ { "billing_class": "facility", "maximum": 411.36, "minimum": 411.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 411.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5926", "type": "HCPCS" } ], "description": "Endoskel posit rotat unit", "standard_charges": [ { "billing_class": "facility", "maximum": 791.74, "minimum": 791.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 791.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5930", "type": "HCPCS" } ], "description": "High activity knee frame", "standard_charges": [ { "billing_class": "facility", "maximum": 4144.66, "minimum": 4144.66, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4144.66 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5940", "type": "HCPCS" } ], "description": "Endo bk ultra-light material", "standard_charges": [ { "billing_class": "facility", "maximum": 614.1, "minimum": 614.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 614.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5950", "type": "HCPCS" } ], "description": "Endo ak ultra-light material", "standard_charges": [ { "billing_class": "facility", "maximum": 952.47, "minimum": 952.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 952.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5960", "type": "HCPCS" } ], "description": "Endo hip ultra-light materia", "standard_charges": [ { "billing_class": "facility", "maximum": 1424.19, "minimum": 1424.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1424.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5961", "type": "HCPCS" } ], "description": "Endo poly hip, pneu/hyd/rot", "standard_charges": [ { "billing_class": "facility", "maximum": 5877.61, "minimum": 5877.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5877.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5962", "type": "HCPCS" } ], "description": "Below knee flex cover system", "standard_charges": [ { "billing_class": "facility", "maximum": 719.6, "minimum": 719.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 719.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5964", "type": "HCPCS" } ], "description": "Above knee flex cover system", "standard_charges": [ { "billing_class": "facility", "maximum": 1380.34, "minimum": 1380.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1380.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5966", "type": "HCPCS" } ], "description": "Hip flexible cover system", "standard_charges": [ { "billing_class": "facility", "maximum": 1778.12, "minimum": 1778.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1778.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5968", "type": "HCPCS" } ], "description": "Multiaxial ankle w dorsiflex", "standard_charges": [ { "billing_class": "facility", "maximum": 4474.62, "minimum": 4474.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4474.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5970", "type": "HCPCS" } ], "description": "Foot external keel sach foot", "standard_charges": [ { "billing_class": "facility", "maximum": 267.47, "minimum": 267.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 267.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5971", "type": "HCPCS" } ], "description": "SACH foot, replacement", "standard_charges": [ { "billing_class": "facility", "maximum": 267.47, "minimum": 267.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 267.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5972", "type": "HCPCS" } ], "description": "Flexible keel foot", "standard_charges": [ { "billing_class": "facility", "maximum": 487.23, "minimum": 487.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 487.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5973", "type": "HCPCS" } ], "description": "Ank-foot sys dors-plant flex", "standard_charges": [ { "billing_class": "facility", "maximum": 21739.52, "minimum": 21739.52, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21739.52 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5974", "type": "HCPCS" } ], "description": "Foot single axis ankle/foot", "standard_charges": [ { "billing_class": "facility", "maximum": 285.29, "minimum": 285.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 285.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5975", "type": "HCPCS" } ], "description": "Combo ankle/foot prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 570.86, "minimum": 570.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 570.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5976", "type": "HCPCS" } ], "description": "Energy storing foot", "standard_charges": [ { "billing_class": "facility", "maximum": 723.64, "minimum": 723.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 723.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5978", "type": "HCPCS" } ], "description": "Ft prosth multiaxial ankl/ft", "standard_charges": [ { "billing_class": "facility", "maximum": 383.44, "minimum": 383.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 383.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5979", "type": "HCPCS" } ], "description": "Multi-axial ankle/ft prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 3070.11, "minimum": 3070.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3070.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5980", "type": "HCPCS" } ], "description": "Flex foot system", "standard_charges": [ { "billing_class": "facility", "maximum": 4677.59, "minimum": 4677.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4677.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5981", "type": "HCPCS" } ], "description": "Flex-walk sys low ext prosth", "standard_charges": [ { "billing_class": "facility", "maximum": 4201.6, "minimum": 4201.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4201.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5982", "type": "HCPCS" } ], "description": "Exoskeletal axial rotation u", "standard_charges": [ { "billing_class": "facility", "maximum": 789.31, "minimum": 789.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 789.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5984", "type": "HCPCS" } ], "description": "Endoskeletal axial rotation", "standard_charges": [ { "billing_class": "facility", "maximum": 791.74, "minimum": 791.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 791.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5985", "type": "HCPCS" } ], "description": "Lwr ext dynamic prosth pylon", "standard_charges": [ { "billing_class": "facility", "maximum": 347.73, "minimum": 347.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 347.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5986", "type": "HCPCS" } ], "description": "Multi-axial rotation unit", "standard_charges": [ { "billing_class": "facility", "maximum": 955.08, "minimum": 955.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 955.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5987", "type": "HCPCS" } ], "description": "Shank ft w vert load pylon", "standard_charges": [ { "billing_class": "facility", "maximum": 8858.1, "minimum": 8858.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8858.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5988", "type": "HCPCS" } ], "description": "Vertical shock reducing pylo", "standard_charges": [ { "billing_class": "facility", "maximum": 2459.87, "minimum": 2459.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2459.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5990", "type": "HCPCS" } ], "description": "User adjustable heel height", "standard_charges": [ { "billing_class": "facility", "maximum": 2233.87, "minimum": 2233.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2233.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L5991", "type": "HCPCS" } ], "description": "Low pros ext osseo connector", "standard_charges": [ { "billing_class": "facility", "maximum": 11755.04, "minimum": 11755.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11755.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6000", "type": "HCPCS" } ], "description": "Part hand thumb rem", "standard_charges": [ { "billing_class": "facility", "maximum": 2168.87, "minimum": 2168.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2168.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6010", "type": "HCPCS" } ], "description": "Part hand little/ring", "standard_charges": [ { "billing_class": "facility", "maximum": 2413.59, "minimum": 2413.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2413.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6020", "type": "HCPCS" } ], "description": "Part hand no fingers", "standard_charges": [ { "billing_class": "facility", "maximum": 2250.28, "minimum": 2250.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2250.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6026", "type": "HCPCS" } ], "description": "Part hand myo exclu term dev", "standard_charges": [ { "billing_class": "facility", "maximum": 5356.25, "minimum": 5356.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5356.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6050", "type": "HCPCS" } ], "description": "Wrst MLd sck flx hng tri pad", "standard_charges": [ { "billing_class": "facility", "maximum": 3060.84, "minimum": 3060.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3060.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6055", "type": "HCPCS" } ], "description": "Wrst mold sock w/exp interfa", "standard_charges": [ { "billing_class": "facility", "maximum": 3904.27, "minimum": 3904.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3904.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6100", "type": "HCPCS" } ], "description": "Elb mold sock flex hinge pad", "standard_charges": [ { "billing_class": "facility", "maximum": 3097.46, "minimum": 3097.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3097.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6110", "type": "HCPCS" } ], "description": "Elbow mold sock suspension t", "standard_charges": [ { "billing_class": "facility", "maximum": 3276.91, "minimum": 3276.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3276.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6120", "type": "HCPCS" } ], "description": "Elbow mold doub splt soc ste", "standard_charges": [ { "billing_class": "facility", "maximum": 3706.2, "minimum": 3706.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3706.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6130", "type": "HCPCS" } ], "description": "Elbow stump activated lock h", "standard_charges": [ { "billing_class": "facility", "maximum": 3910.12, "minimum": 3910.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3910.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6200", "type": "HCPCS" } ], "description": "Elbow mold outsid lock hinge", "standard_charges": [ { "billing_class": "facility", "maximum": 4027.88, "minimum": 4027.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4027.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6205", "type": "HCPCS" } ], "description": "Elbow molded w/ expand inter", "standard_charges": [ { "billing_class": "facility", "maximum": 5556.38, "minimum": 5556.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5556.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6250", "type": "HCPCS" } ], "description": "Elbow inter loc elbow forarm", "standard_charges": [ { "billing_class": "facility", "maximum": 3962.73, "minimum": 3962.73, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3962.73 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6300", "type": "HCPCS" } ], "description": "Shlder disart int lock elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 5465.7, "minimum": 5465.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5465.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6310", "type": "HCPCS" } ], "description": "Shoulder passive restor comp", "standard_charges": [ { "billing_class": "facility", "maximum": 4953.47, "minimum": 4953.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4953.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6320", "type": "HCPCS" } ], "description": "Shoulder passive restor cap", "standard_charges": [ { "billing_class": "facility", "maximum": 2581.59, "minimum": 2581.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2581.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6350", "type": "HCPCS" } ], "description": "Thoracic intern lock elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 5988.72, "minimum": 5988.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5988.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6360", "type": "HCPCS" } ], "description": "Thoracic passive restor comp", "standard_charges": [ { "billing_class": "facility", "maximum": 5199.26, "minimum": 5199.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5199.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6370", "type": "HCPCS" } ], "description": "Thoracic passive restor cap", "standard_charges": [ { "billing_class": "facility", "maximum": 3015.22, "minimum": 3015.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3015.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6380", "type": "HCPCS" } ], "description": "Postop dsg cast chg wrst/elb", "standard_charges": [ { "billing_class": "facility", "maximum": 1743.91, "minimum": 1743.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1743.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6382", "type": "HCPCS" } ], "description": "Postop dsg cast chg elb dis/", "standard_charges": [ { "billing_class": "facility", "maximum": 2076.05, "minimum": 2076.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2076.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6384", "type": "HCPCS" } ], "description": "Postop dsg cast chg shlder/t", "standard_charges": [ { "billing_class": "facility", "maximum": 2626.33, "minimum": 2626.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2626.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6386", "type": "HCPCS" } ], "description": "Postop ea cast chg & realign", "standard_charges": [ { "billing_class": "facility", "maximum": 575.71, "minimum": 575.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 575.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6388", "type": "HCPCS" } ], "description": "Postop applicat rigid dsg on", "standard_charges": [ { "billing_class": "facility", "maximum": 633.99, "minimum": 633.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 633.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6400", "type": "HCPCS" } ], "description": "Below elbow prosth tiss shap", "standard_charges": [ { "billing_class": "facility", "maximum": 3350.67, "minimum": 3350.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3350.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6450", "type": "HCPCS" } ], "description": "Elb disart prosth tiss shap", "standard_charges": [ { "billing_class": "facility", "maximum": 4379.16, "minimum": 4379.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4379.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6500", "type": "HCPCS" } ], "description": "Above elbow prosth tiss shap", "standard_charges": [ { "billing_class": "facility", "maximum": 4300.25, "minimum": 4300.25, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4300.25 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6550", "type": "HCPCS" } ], "description": "Shldr disar prosth tiss shap", "standard_charges": [ { "billing_class": "facility", "maximum": 5569.71, "minimum": 5569.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5569.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6570", "type": "HCPCS" } ], "description": "Scap thorac prosth tiss shap", "standard_charges": [ { "billing_class": "facility", "maximum": 6217.85, "minimum": 6217.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6217.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6580", "type": "HCPCS" } ], "description": "Wrist/elbow bowden cable mol", "standard_charges": [ { "billing_class": "facility", "maximum": 2486.04, "minimum": 2486.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2486.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6582", "type": "HCPCS" } ], "description": "Wrist/elbow bowden cbl dir f", "standard_charges": [ { "billing_class": "facility", "maximum": 2087.94, "minimum": 2087.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2087.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6584", "type": "HCPCS" } ], "description": "Elbow fair lead cable molded", "standard_charges": [ { "billing_class": "facility", "maximum": 3091.67, "minimum": 3091.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3091.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6586", "type": "HCPCS" } ], "description": "Elbow fair lead cable dir fo", "standard_charges": [ { "billing_class": "facility", "maximum": 2754.87, "minimum": 2754.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2754.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6588", "type": "HCPCS" } ], "description": "Shdr fair lead cable molded", "standard_charges": [ { "billing_class": "facility", "maximum": 4387.49, "minimum": 4387.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4387.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6590", "type": "HCPCS" } ], "description": "Shdr fair lead cable direct", "standard_charges": [ { "billing_class": "facility", "maximum": 3823.85, "minimum": 3823.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3823.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6600", "type": "HCPCS" } ], "description": "Polycentric hinge pair", "standard_charges": [ { "billing_class": "facility", "maximum": 279.3, "minimum": 279.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 279.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6605", "type": "HCPCS" } ], "description": "Single pivot hinge pair", "standard_charges": [ { "billing_class": "facility", "maximum": 287.48, "minimum": 287.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 287.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6610", "type": "HCPCS" } ], "description": "Flexible metal hinge pair", "standard_charges": [ { "billing_class": "facility", "maximum": 271.77, "minimum": 271.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 271.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6611", "type": "HCPCS" } ], "description": "Additional switch, ext power", "standard_charges": [ { "billing_class": "facility", "maximum": 506.97, "minimum": 506.97, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 506.97 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6615", "type": "HCPCS" } ], "description": "Disconnect locking wrist uni", "standard_charges": [ { "billing_class": "facility", "maximum": 263.8, "minimum": 263.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 263.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6616", "type": "HCPCS" } ], "description": "Disconnect insert locking wr", "standard_charges": [ { "billing_class": "facility", "maximum": 79.41, "minimum": 79.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6620", "type": "HCPCS" } ], "description": "Flexion/extension wrist unit", "standard_charges": [ { "billing_class": "facility", "maximum": 461.17, "minimum": 461.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 461.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6621", "type": "HCPCS" } ], "description": "Flex/ext wrist w/wo friction", "standard_charges": [ { "billing_class": "facility", "maximum": 2816.5, "minimum": 2816.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2816.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6623", "type": "HCPCS" } ], "description": "Spring-ass rot wrst w/ latch", "standard_charges": [ { "billing_class": "facility", "maximum": 878.53, "minimum": 878.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 878.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6624", "type": "HCPCS" } ], "description": "Flex/ext/rotation wrist unit", "standard_charges": [ { "billing_class": "facility", "maximum": 4637.39, "minimum": 4637.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4637.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6625", "type": "HCPCS" } ], "description": "Rotation wrst w/ cable lock", "standard_charges": [ { "billing_class": "facility", "maximum": 651.11, "minimum": 651.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 651.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6628", "type": "HCPCS" } ], "description": "Quick disconn hook adapter o", "standard_charges": [ { "billing_class": "facility", "maximum": 700.86, "minimum": 700.86, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 700.86 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6629", "type": "HCPCS" } ], "description": "Lamination collar w/ couplin", "standard_charges": [ { "billing_class": "facility", "maximum": 238.81, "minimum": 238.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 238.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6630", "type": "HCPCS" } ], "description": "Stainless steel any wrist", "standard_charges": [ { "billing_class": "facility", "maximum": 351.8, "minimum": 351.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 351.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6632", "type": "HCPCS" } ], "description": "Latex suspension sleeve each", "standard_charges": [ { "billing_class": "facility", "maximum": 79.54, "minimum": 79.54, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.54 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6635", "type": "HCPCS" } ], "description": "Lift assist for elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 254.26, "minimum": 254.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 254.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6637", "type": "HCPCS" } ], "description": "Nudge control elbow lock", "standard_charges": [ { "billing_class": "facility", "maximum": 497.8, "minimum": 497.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 497.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6638", "type": "HCPCS" } ], "description": "Elec lock on manual pw elbow", "standard_charges": [ { "billing_class": "facility", "maximum": 3079.31, "minimum": 3079.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3079.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6640", "type": "HCPCS" } ], "description": "Shoulder abduction joint pai", "standard_charges": [ { "billing_class": "facility", "maximum": 414.58, "minimum": 414.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 414.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6641", "type": "HCPCS" } ], "description": "Excursion amplifier pulley t", "standard_charges": [ { "billing_class": "facility", "maximum": 241.41, "minimum": 241.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 241.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6642", "type": "HCPCS" } ], "description": "Excursion amplifier lever ty", "standard_charges": [ { "billing_class": "facility", "maximum": 354.94, "minimum": 354.94, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 354.94 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6645", "type": "HCPCS" } ], "description": "Shoulder flexion-abduction j", "standard_charges": [ { "billing_class": "facility", "maximum": 448.35, "minimum": 448.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 448.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6646", "type": "HCPCS" } ], "description": "Multipo locking shoulder jnt", "standard_charges": [ { "billing_class": "facility", "maximum": 3883.7, "minimum": 3883.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3883.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6647", "type": "HCPCS" } ], "description": "Shoulder lock actuator", "standard_charges": [ { "billing_class": "facility", "maximum": 639.39, "minimum": 639.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 639.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6648", "type": "HCPCS" } ], "description": "Ext pwrd shlder lock/unlock", "standard_charges": [ { "billing_class": "facility", "maximum": 4005.49, "minimum": 4005.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4005.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6650", "type": "HCPCS" } ], "description": "Shoulder universal joint", "standard_charges": [ { "billing_class": "facility", "maximum": 486.29, "minimum": 486.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 486.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6655", "type": "HCPCS" } ], "description": "Standard control cable extra", "standard_charges": [ { "billing_class": "facility", "maximum": 94.34, "minimum": 94.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 94.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6660", "type": "HCPCS" } ], "description": "Heavy duty control cable", "standard_charges": [ { "billing_class": "facility", "maximum": 126.24, "minimum": 126.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 126.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6665", "type": "HCPCS" } ], "description": "Teflon or equal cable lining", "standard_charges": [ { "billing_class": "facility", "maximum": 56.38, "minimum": 56.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 56.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6670", "type": "HCPCS" } ], "description": "Hook to hand cable adapter", "standard_charges": [ { "billing_class": "facility", "maximum": 58.71, "minimum": 58.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 58.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6672", "type": "HCPCS" } ], "description": "Harness chest/shlder saddle", "standard_charges": [ { "billing_class": "facility", "maximum": 269.43, "minimum": 269.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 269.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6675", "type": "HCPCS" } ], "description": "Harness figure of 8 sing con", "standard_charges": [ { "billing_class": "facility", "maximum": 147.02, "minimum": 147.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 147.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6676", "type": "HCPCS" } ], "description": "Harness figure of 8 dual con", "standard_charges": [ { "billing_class": "facility", "maximum": 153.82, "minimum": 153.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 153.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6677", "type": "HCPCS" } ], "description": "UE triple control harness", "standard_charges": [ { "billing_class": "facility", "maximum": 365.26, "minimum": 365.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 365.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6680", "type": "HCPCS" } ], "description": "Test sock wrist disart/bel e", "standard_charges": [ { "billing_class": "facility", "maximum": 378.71, "minimum": 378.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 378.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6682", "type": "HCPCS" } ], "description": "Test sock elbw disart/above", "standard_charges": [ { "billing_class": "facility", "maximum": 418.71, "minimum": 418.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 418.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6684", "type": "HCPCS" } ], "description": "Test socket shldr disart/tho", "standard_charges": [ { "billing_class": "facility", "maximum": 568.98, "minimum": 568.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 568.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6686", "type": "HCPCS" } ], "description": "Suction socket", "standard_charges": [ { "billing_class": "facility", "maximum": 844.29, "minimum": 844.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 844.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6687", "type": "HCPCS" } ], "description": "Frame typ socket bel elbow/w", "standard_charges": [ { "billing_class": "facility", "maximum": 706.16, "minimum": 706.16, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 706.16 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6688", "type": "HCPCS" } ], "description": "Frame typ sock above elb/dis", "standard_charges": [ { "billing_class": "facility", "maximum": 781.53, "minimum": 781.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 781.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6689", "type": "HCPCS" } ], "description": "Frame typ socket shoulder di", "standard_charges": [ { "billing_class": "facility", "maximum": 931.44, "minimum": 931.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 931.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6690", "type": "HCPCS" } ], "description": "Frame typ sock interscap-tho", "standard_charges": [ { "billing_class": "facility", "maximum": 1096.63, "minimum": 1096.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1096.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6691", "type": "HCPCS" } ], "description": "Removable insert each", "standard_charges": [ { "billing_class": "facility", "maximum": 432.88, "minimum": 432.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 432.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6692", "type": "HCPCS" } ], "description": "Silicone gel insert or equal", "standard_charges": [ { "billing_class": "facility", "maximum": 787.53, "minimum": 787.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 787.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6693", "type": "HCPCS" } ], "description": "Lockingelbow forearm cntrbal", "standard_charges": [ { "billing_class": "facility", "maximum": 3495.85, "minimum": 3495.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3495.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6694", "type": "HCPCS" } ], "description": "Elbow socket ins use w/lock", "standard_charges": [ { "billing_class": "facility", "maximum": 967.82, "minimum": 967.82, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 967.82 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6695", "type": "HCPCS" } ], "description": "Elbow socket ins use w/o lck", "standard_charges": [ { "billing_class": "facility", "maximum": 806.49, "minimum": 806.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 806.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6696", "type": "HCPCS" } ], "description": "Cus elbo skt in for con/atyp", "standard_charges": [ { "billing_class": "facility", "maximum": 1619.74, "minimum": 1619.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1619.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6697", "type": "HCPCS" } ], "description": "Cus elbo skt in not con/atyp", "standard_charges": [ { "billing_class": "facility", "maximum": 1619.74, "minimum": 1619.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1619.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6698", "type": "HCPCS" } ], "description": "Below/above elbow lock mech", "standard_charges": [ { "billing_class": "facility", "maximum": 608.96, "minimum": 608.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 608.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6700", "type": "HCPCS" } ], "description": "Ue add ext power myoel", "standard_charges": [ { "billing_class": "facility", "maximum": 29510.19, "minimum": 29510.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29510.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6703", "type": "HCPCS" } ], "description": "Term dev, passive hand mitt", "standard_charges": [ { "billing_class": "facility", "maximum": 430.7, "minimum": 430.7, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.7 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6704", "type": "HCPCS" } ], "description": "Term dev, sport/rec/work att", "standard_charges": [ { "billing_class": "facility", "maximum": 831.35, "minimum": 831.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 831.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6706", "type": "HCPCS" } ], "description": "Term dev mech hook vol open", "standard_charges": [ { "billing_class": "facility", "maximum": 515.91, "minimum": 515.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 515.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6707", "type": "HCPCS" } ], "description": "Term dev mech hook vol close", "standard_charges": [ { "billing_class": "facility", "maximum": 1825.05, "minimum": 1825.05, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1825.05 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6708", "type": "HCPCS" } ], "description": "Term dev mech hand vol open", "standard_charges": [ { "billing_class": "facility", "maximum": 1206.42, "minimum": 1206.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1206.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6709", "type": "HCPCS" } ], "description": "Term dev mech hand vol close", "standard_charges": [ { "billing_class": "facility", "maximum": 1712.21, "minimum": 1712.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1712.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6711", "type": "HCPCS" } ], "description": "Ped term dev, hook, vol open", "standard_charges": [ { "billing_class": "facility", "maximum": 827.85, "minimum": 827.85, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 827.85 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6712", "type": "HCPCS" } ], "description": "Ped term dev, hook, vol clos", "standard_charges": [ { "billing_class": "facility", "maximum": 1524.28, "minimum": 1524.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1524.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6713", "type": "HCPCS" } ], "description": "Ped term dev, hand, vol open", "standard_charges": [ { "billing_class": "facility", "maximum": 1923.74, "minimum": 1923.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1923.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6714", "type": "HCPCS" } ], "description": "Ped term dev, hand, vol clos", "standard_charges": [ { "billing_class": "facility", "maximum": 1629.4, "minimum": 1629.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1629.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6715", "type": "HCPCS" } ], "description": "Term device, multi art digit", "standard_charges": [ { "billing_class": "facility", "maximum": 3887.6, "minimum": 3887.6, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3887.6 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6721", "type": "HCPCS" } ], "description": "Hook/hand, hvy dty, vol open", "standard_charges": [ { "billing_class": "facility", "maximum": 2896.15, "minimum": 2896.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2896.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6722", "type": "HCPCS" } ], "description": "Hook/hand, hvy dty, vol clos", "standard_charges": [ { "billing_class": "facility", "maximum": 2496.64, "minimum": 2496.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2496.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6805", "type": "HCPCS" } ], "description": "Term dev modifier wrist unit", "standard_charges": [ { "billing_class": "facility", "maximum": 472.26, "minimum": 472.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 472.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6810", "type": "HCPCS" } ], "description": "Term dev precision pinch dev", "standard_charges": [ { "billing_class": "facility", "maximum": 251.06, "minimum": 251.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 251.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6880", "type": "HCPCS" } ], "description": "Elec hand ind art digits", "standard_charges": [ { "billing_class": "facility", "maximum": 29420.21, "minimum": 29420.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29420.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6881", "type": "HCPCS" } ], "description": "Term dev auto grasp feature", "standard_charges": [ { "billing_class": "facility", "maximum": 5034.12, "minimum": 5034.12, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5034.12 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6882", "type": "HCPCS" } ], "description": "Microprocessor control uplmb", "standard_charges": [ { "billing_class": "facility", "maximum": 3818.61, "minimum": 3818.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3818.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6883", "type": "HCPCS" } ], "description": "Replc sockt below e/w disa", "standard_charges": [ { "billing_class": "facility", "maximum": 2446.07, "minimum": 2446.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2446.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6884", "type": "HCPCS" } ], "description": "Replc sockt above elbow disa", "standard_charges": [ { "billing_class": "facility", "maximum": 3346.77, "minimum": 3346.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3346.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6885", "type": "HCPCS" } ], "description": "Replc sockt shldr dis/interc", "standard_charges": [ { "billing_class": "facility", "maximum": 5199.26, "minimum": 5199.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5199.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6890", "type": "HCPCS" } ], "description": "Prefab glove for term device", "standard_charges": [ { "billing_class": "facility", "maximum": 245.93, "minimum": 245.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 245.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6895", "type": "HCPCS" } ], "description": "Custom glove for term device", "standard_charges": [ { "billing_class": "facility", "maximum": 822.33, "minimum": 822.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 822.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6900", "type": "HCPCS" } ], "description": "Hand restorat thumb/1 finger", "standard_charges": [ { "billing_class": "facility", "maximum": 2387.98, "minimum": 2387.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2387.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6905", "type": "HCPCS" } ], "description": "Hand restoration multiple fi", "standard_charges": [ { "billing_class": "facility", "maximum": 2363.43, "minimum": 2363.43, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2363.43 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6910", "type": "HCPCS" } ], "description": "Hand restoration no fingers", "standard_charges": [ { "billing_class": "facility", "maximum": 2323.42, "minimum": 2323.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2323.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6915", "type": "HCPCS" } ], "description": "Hand restoration replacmnt g", "standard_charges": [ { "billing_class": "facility", "maximum": 998.28, "minimum": 998.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 998.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6920", "type": "HCPCS" } ], "description": "Wrist disarticul switch ctrl", "standard_charges": [ { "billing_class": "facility", "maximum": 10315.01, "minimum": 10315.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10315.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6925", "type": "HCPCS" } ], "description": "Wrist disart myoelectronic c", "standard_charges": [ { "billing_class": "facility", "maximum": 11019.87, "minimum": 11019.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11019.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6930", "type": "HCPCS" } ], "description": "Below elbow switch control", "standard_charges": [ { "billing_class": "facility", "maximum": 9934.8, "minimum": 9934.8, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9934.8 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6935", "type": "HCPCS" } ], "description": "Below elbow myoelectronic ct", "standard_charges": [ { "billing_class": "facility", "maximum": 10968.08, "minimum": 10968.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10968.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6940", "type": "HCPCS" } ], "description": "Elbow disarticulation switch", "standard_charges": [ { "billing_class": "facility", "maximum": 12829.08, "minimum": 12829.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12829.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6945", "type": "HCPCS" } ], "description": "Elbow disart myoelectronic c", "standard_charges": [ { "billing_class": "facility", "maximum": 14312.5, "minimum": 14312.5, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14312.5 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6950", "type": "HCPCS" } ], "description": "Above elbow switch control", "standard_charges": [ { "billing_class": "facility", "maximum": 12805.28, "minimum": 12805.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 12805.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6955", "type": "HCPCS" } ], "description": "Above elbow myoelectronic ct", "standard_charges": [ { "billing_class": "facility", "maximum": 14850.1, "minimum": 14850.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14850.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6960", "type": "HCPCS" } ], "description": "Shldr disartic switch contro", "standard_charges": [ { "billing_class": "facility", "maximum": 15621.74, "minimum": 15621.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15621.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6965", "type": "HCPCS" } ], "description": "Shldr disartic myoelectronic", "standard_charges": [ { "billing_class": "facility", "maximum": 18506.37, "minimum": 18506.37, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18506.37 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6970", "type": "HCPCS" } ], "description": "Interscapular-thor switch ct", "standard_charges": [ { "billing_class": "facility", "maximum": 19809.02, "minimum": 19809.02, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19809.02 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L6975", "type": "HCPCS" } ], "description": "Interscap-thor myoelectronic", "standard_charges": [ { "billing_class": "facility", "maximum": 21834.21, "minimum": 21834.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 21834.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7007", "type": "HCPCS" } ], "description": "Adult electric hand", "standard_charges": [ { "billing_class": "facility", "maximum": 4497.55, "minimum": 4497.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4497.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7008", "type": "HCPCS" } ], "description": "Pediatric electric hand", "standard_charges": [ { "billing_class": "facility", "maximum": 6974.35, "minimum": 6974.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6974.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7009", "type": "HCPCS" } ], "description": "Adult electric hook", "standard_charges": [ { "billing_class": "facility", "maximum": 4601.53, "minimum": 4601.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4601.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7040", "type": "HCPCS" } ], "description": "Prehensile actuator", "standard_charges": [ { "billing_class": "facility", "maximum": 3745.35, "minimum": 3745.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3745.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7045", "type": "HCPCS" } ], "description": "Pediatric electric hook", "standard_charges": [ { "billing_class": "facility", "maximum": 1978.79, "minimum": 1978.79, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1978.79 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7170", "type": "HCPCS" } ], "description": "Electronic elbow hosmer swit", "standard_charges": [ { "billing_class": "facility", "maximum": 7406.87, "minimum": 7406.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7406.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7180", "type": "HCPCS" } ], "description": "Electronic elbow sequential", "standard_charges": [ { "billing_class": "facility", "maximum": 47919.99, "minimum": 47919.99, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 47919.99 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7181", "type": "HCPCS" } ], "description": "Electronic elbo simultaneous", "standard_charges": [ { "billing_class": "facility", "maximum": 49338.18, "minimum": 49338.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 49338.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7185", "type": "HCPCS" } ], "description": "Electron elbow adolescent sw", "standard_charges": [ { "billing_class": "facility", "maximum": 7787.04, "minimum": 7787.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7787.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7186", "type": "HCPCS" } ], "description": "Electron elbow child switch", "standard_charges": [ { "billing_class": "facility", "maximum": 13091.11, "minimum": 13091.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13091.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7190", "type": "HCPCS" } ], "description": "Elbow adolescent myoelectron", "standard_charges": [ { "billing_class": "facility", "maximum": 10332.65, "minimum": 10332.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10332.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7191", "type": "HCPCS" } ], "description": "Elbow child myoelectronic ct", "standard_charges": [ { "billing_class": "facility", "maximum": 13769.77, "minimum": 13769.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 13769.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7259", "type": "HCPCS" } ], "description": "Electronic wrist rotator any", "standard_charges": [ { "billing_class": "facility", "maximum": 5046.41, "minimum": 5046.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5046.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7360", "type": "HCPCS" } ], "description": "Six volt bat otto bock/eq ea", "standard_charges": [ { "billing_class": "facility", "maximum": 325.76, "minimum": 325.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 325.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7362", "type": "HCPCS" } ], "description": "Battery chrgr six volt otto", "standard_charges": [ { "billing_class": "facility", "maximum": 355.87, "minimum": 355.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 355.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7364", "type": "HCPCS" } ], "description": "Twelve volt battery utah/equ", "standard_charges": [ { "billing_class": "facility", "maximum": 629.69, "minimum": 629.69, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 629.69 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7366", "type": "HCPCS" } ], "description": "Battery chrgr 12 volt utah/e", "standard_charges": [ { "billing_class": "facility", "maximum": 865.98, "minimum": 865.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 865.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7367", "type": "HCPCS" } ], "description": "Replacemnt lithium ionbatter", "standard_charges": [ { "billing_class": "facility", "maximum": 479.42, "minimum": 479.42, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 479.42 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7368", "type": "HCPCS" } ], "description": "Lithium ion battery charger", "standard_charges": [ { "billing_class": "facility", "maximum": 621.46, "minimum": 621.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 621.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7400", "type": "HCPCS" } ], "description": "Add ue prost be/wd, ultlite", "standard_charges": [ { "billing_class": "facility", "maximum": 377.39, "minimum": 377.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 377.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7401", "type": "HCPCS" } ], "description": "Add ue prost a/e ultlite mat", "standard_charges": [ { "billing_class": "facility", "maximum": 422.45, "minimum": 422.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 422.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7402", "type": "HCPCS" } ], "description": "Add ue prost s/d ultlite mat", "standard_charges": [ { "billing_class": "facility", "maximum": 456.27, "minimum": 456.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 456.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7403", "type": "HCPCS" } ], "description": "Add UE prost b/e acrylic", "standard_charges": [ { "billing_class": "facility", "maximum": 453.48, "minimum": 453.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 453.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7404", "type": "HCPCS" } ], "description": "Add UE prost a/e acrylic", "standard_charges": [ { "billing_class": "facility", "maximum": 684.45, "minimum": 684.45, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 684.45 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7405", "type": "HCPCS" } ], "description": "Add UE prost s/d acrylic", "standard_charges": [ { "billing_class": "facility", "maximum": 895.08, "minimum": 895.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 895.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7406", "type": "HCPCS" } ], "description": "Add to upp extr user adj mec", "standard_charges": [ { "billing_class": "facility", "maximum": 3150.07, "minimum": 3150.07, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3150.07 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7520", "type": "HCPCS" } ], "description": "Repair prosthesis per 15 min", "standard_charges": [ { "billing_class": "facility", "maximum": 40.67, "minimum": 40.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 40.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L7700", "type": "HCPCS" } ], "description": "Pros soc insert gasket/seal", "standard_charges": [ { "billing_class": "facility", "maximum": 184.22, "minimum": 184.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 184.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8000", "type": "HCPCS" } ], "description": "Mastectomy bra", "standard_charges": [ { "billing_class": "facility", "maximum": 52.13, "minimum": 52.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 52.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8001", "type": "HCPCS" } ], "description": "Breast prosthesis bra & form", "standard_charges": [ { "billing_class": "facility", "maximum": 154.49, "minimum": 154.49, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 154.49 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8002", "type": "HCPCS" } ], "description": "Brst prsth bra & bilat form", "standard_charges": [ { "billing_class": "facility", "maximum": 203.15, "minimum": 203.15, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 203.15 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8015", "type": "HCPCS" } ], "description": "Ext breastprosthesis garment", "standard_charges": [ { "billing_class": "facility", "maximum": 73.81, "minimum": 73.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 73.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8020", "type": "HCPCS" } ], "description": "Mastectomy form", "standard_charges": [ { "billing_class": "facility", "maximum": 278.4, "minimum": 278.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 278.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8030", "type": "HCPCS" } ], "description": "Breast prosthes w/o adhesive", "standard_charges": [ { "billing_class": "facility", "maximum": 430.39, "minimum": 430.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8031", "type": "HCPCS" } ], "description": "Breast prosthesis w adhesive", "standard_charges": [ { "billing_class": "facility", "maximum": 430.39, "minimum": 430.39, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 430.39 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8032", "type": "HCPCS" } ], "description": "Reusable nipple prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 48.23, "minimum": 48.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 48.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8035", "type": "HCPCS" } ], "description": "Custom breast prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 4511.21, "minimum": 4511.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4511.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8040", "type": "HCPCS" } ], "description": "Nasal prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 3052.75, "minimum": 3052.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3052.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8041", "type": "HCPCS" } ], "description": "Midfacial prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 3679.2, "minimum": 3679.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3679.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8042", "type": "HCPCS" } ], "description": "Orbital prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 4133.93, "minimum": 4133.93, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4133.93 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8043", "type": "HCPCS" } ], "description": "Upper facial prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 4630.01, "minimum": 4630.01, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4630.01 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8044", "type": "HCPCS" } ], "description": "Hemi-facial prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 5126.08, "minimum": 5126.08, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5126.08 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8045", "type": "HCPCS" } ], "description": "Auricular prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 4014.06, "minimum": 4014.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4014.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8046", "type": "HCPCS" } ], "description": "Partial facial prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 3307.18, "minimum": 3307.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 3307.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8047", "type": "HCPCS" } ], "description": "Nasal septal prosthesis", "standard_charges": [ { "billing_class": "facility", "maximum": 1694.92, "minimum": 1694.92, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1694.92 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8300", "type": "HCPCS" } ], "description": "Truss single w/ standard pad", "standard_charges": [ { "billing_class": "facility", "maximum": 103.28, "minimum": 103.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 103.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8310", "type": "HCPCS" } ], "description": "Truss double w/ standard pad", "standard_charges": [ { "billing_class": "facility", "maximum": 182.95, "minimum": 182.95, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 182.95 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8320", "type": "HCPCS" } ], "description": "Truss addition to std pad wa", "standard_charges": [ { "billing_class": "facility", "maximum": 75.9, "minimum": 75.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8330", "type": "HCPCS" } ], "description": "Truss add to std pad scrotal", "standard_charges": [ { "billing_class": "facility", "maximum": 60.44, "minimum": 60.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 60.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8400", "type": "HCPCS" } ], "description": "Sheath below knee", "standard_charges": [ { "billing_class": "facility", "maximum": 19.27, "minimum": 19.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8410", "type": "HCPCS" } ], "description": "Sheath above knee", "standard_charges": [ { "billing_class": "facility", "maximum": 25.36, "minimum": 25.36, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.36 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8415", "type": "HCPCS" } ], "description": "Sheath upper limb", "standard_charges": [ { "billing_class": "facility", "maximum": 26.24, "minimum": 26.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8417", "type": "HCPCS" } ], "description": "Pros sheath/sock w gel cushn", "standard_charges": [ { "billing_class": "facility", "maximum": 92.62, "minimum": 92.62, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 92.62 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8420", "type": "HCPCS" } ], "description": "Prosthetic sock multi ply BK", "standard_charges": [ { "billing_class": "facility", "maximum": 25.68, "minimum": 25.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8430", "type": "HCPCS" } ], "description": "Prosthetic sock multi ply AK", "standard_charges": [ { "billing_class": "facility", "maximum": 29.09, "minimum": 29.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8435", "type": "HCPCS" } ], "description": "Pros sock multi ply upper lm", "standard_charges": [ { "billing_class": "facility", "maximum": 27.64, "minimum": 27.64, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 27.64 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8440", "type": "HCPCS" } ], "description": "Shrinker below knee", "standard_charges": [ { "billing_class": "facility", "maximum": 57.4, "minimum": 57.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 57.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8460", "type": "HCPCS" } ], "description": "Shrinker above knee", "standard_charges": [ { "billing_class": "facility", "maximum": 81.59, "minimum": 81.59, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 81.59 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8465", "type": "HCPCS" } ], "description": "Shrinker upper limb", "standard_charges": [ { "billing_class": "facility", "maximum": 75.41, "minimum": 75.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 75.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8470", "type": "HCPCS" } ], "description": "Pros sock single ply BK", "standard_charges": [ { "billing_class": "facility", "maximum": 8.17, "minimum": 8.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8480", "type": "HCPCS" } ], "description": "Pros sock single ply AK", "standard_charges": [ { "billing_class": "facility", "maximum": 11.27, "minimum": 11.27, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.27 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8485", "type": "HCPCS" } ], "description": "Pros sock single ply upper l", "standard_charges": [ { "billing_class": "facility", "maximum": 15.17, "minimum": 15.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 15.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8500", "type": "HCPCS" } ], "description": "Artificial larynx", "standard_charges": [ { "billing_class": "facility", "maximum": 810.32, "minimum": 810.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 810.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8501", "type": "HCPCS" } ], "description": "Tracheostomy speaking valve", "standard_charges": [ { "billing_class": "facility", "maximum": 147.88, "minimum": 147.88, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 147.88 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8507", "type": "HCPCS" } ], "description": "Trach-esoph voice pros pt in", "standard_charges": [ { "billing_class": "facility", "maximum": 51.55, "minimum": 51.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 51.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8509", "type": "HCPCS" } ], "description": "Trach-esoph voice pros md in", "standard_charges": [ { "billing_class": "facility", "maximum": 134.48, "minimum": 134.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 134.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8510", "type": "HCPCS" } ], "description": "Voice amplifier", "standard_charges": [ { "billing_class": "facility", "maximum": 311.17, "minimum": 311.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 311.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8511", "type": "HCPCS" } ], "description": "Indwelling trach insert", "standard_charges": [ { "billing_class": "facility", "maximum": 89.55, "minimum": 89.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 89.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8512", "type": "HCPCS" } ], "description": "Gel cap for trach voice pros", "standard_charges": [ { "billing_class": "facility", "maximum": 2.68, "minimum": 2.68, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2.68 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8513", "type": "HCPCS" } ], "description": "Trach pros cleaning device", "standard_charges": [ { "billing_class": "facility", "maximum": 6.41, "minimum": 6.41, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6.41 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8514", "type": "HCPCS" } ], "description": "Repl trach puncture dilator", "standard_charges": [ { "billing_class": "facility", "maximum": 116.13, "minimum": 116.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 116.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8515", "type": "HCPCS" } ], "description": "Gel cap app device for trach", "standard_charges": [ { "billing_class": "facility", "maximum": 77.74, "minimum": 77.74, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 77.74 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8615", "type": "HCPCS" } ], "description": "Coch implant headset replace", "standard_charges": [ { "billing_class": "facility", "maximum": 555.35, "minimum": 555.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 555.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8616", "type": "HCPCS" } ], "description": "Coch implant microphone repl", "standard_charges": [ { "billing_class": "facility", "maximum": 129.34, "minimum": 129.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 129.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8617", "type": "HCPCS" } ], "description": "Coch implant trans coil repl", "standard_charges": [ { "billing_class": "facility", "maximum": 112.98, "minimum": 112.98, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 112.98 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8618", "type": "HCPCS" } ], "description": "Coch implant tran cable repl", "standard_charges": [ { "billing_class": "facility", "maximum": 32.29, "minimum": 32.29, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 32.29 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8619", "type": "HCPCS" } ], "description": "Coch imp ext proc/contr rplc", "standard_charges": [ { "billing_class": "facility", "maximum": 10350.06, "minimum": 10350.06, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10350.06 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8621", "type": "HCPCS" } ], "description": "Repl zinc air battery", "standard_charges": [ { "billing_class": "facility", "maximum": 0.77, "minimum": 0.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8622", "type": "HCPCS" } ], "description": "Repl alkaline battery", "standard_charges": [ { "billing_class": "facility", "maximum": 0.4, "minimum": 0.4, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 0.4 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8623", "type": "HCPCS" } ], "description": "Lith ion batt cid,non-earlvl", "standard_charges": [ { "billing_class": "facility", "maximum": 79.65, "minimum": 79.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 79.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8624", "type": "HCPCS" } ], "description": "Lith ion batt cid, ear level", "standard_charges": [ { "billing_class": "facility", "maximum": 198.57, "minimum": 198.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 198.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8625", "type": "HCPCS" } ], "description": "Charger coch impl/aoi battry", "standard_charges": [ { "billing_class": "facility", "maximum": 232.57, "minimum": 232.57, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 232.57 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8627", "type": "HCPCS" } ], "description": "CID ext speech process repl", "standard_charges": [ { "billing_class": "facility", "maximum": 8784.91, "minimum": 8784.91, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 8784.91 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8628", "type": "HCPCS" } ], "description": "CID ext controller repl", "standard_charges": [ { "billing_class": "facility", "maximum": 1565.13, "minimum": 1565.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1565.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8629", "type": "HCPCS" } ], "description": "CID transmit coil and cable", "standard_charges": [ { "billing_class": "facility", "maximum": 220.48, "minimum": 220.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 220.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8681", "type": "HCPCS" } ], "description": "Pt prgrm for implt neurostim", "standard_charges": [ { "billing_class": "facility", "maximum": 1404.38, "minimum": 1404.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1404.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8683", "type": "HCPCS" } ], "description": "Radiofq trsmtr for implt neu", "standard_charges": [ { "billing_class": "facility", "maximum": 6635.61, "minimum": 6635.61, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 6635.61 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8684", "type": "HCPCS" } ], "description": "Radiof trsmtr implt scrl neu", "standard_charges": [ { "billing_class": "facility", "maximum": 1041.21, "minimum": 1041.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1041.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8689", "type": "HCPCS" } ], "description": "External recharg sys intern", "standard_charges": [ { "billing_class": "facility", "maximum": 2124.03, "minimum": 2124.03, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2124.03 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8691", "type": "HCPCS" } ], "description": "Osseointegrated snd proc rpl", "standard_charges": [ { "billing_class": "facility", "maximum": 2120.58, "minimum": 2120.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 2120.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8694", "type": "HCPCS" } ], "description": "Aoi transducer/actuator repl", "standard_charges": [ { "billing_class": "facility", "maximum": 1162.87, "minimum": 1162.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1162.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8695", "type": "HCPCS" } ], "description": "External recharg sys extern", "standard_charges": [ { "billing_class": "facility", "maximum": 20.53, "minimum": 20.53, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.53 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8701", "type": "HCPCS" } ], "description": "Pow ue rom dev ewh uprt cust", "standard_charges": [ { "billing_class": "facility", "maximum": 34970.13, "minimum": 34970.13, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 34970.13 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "L8702", "type": "HCPCS" } ], "description": "Pow ue rom dev ewhf uprt cus", "standard_charges": [ { "billing_class": "facility", "maximum": 68801.71, "minimum": 68801.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 68801.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0477", "type": "HCPCS" } ], "description": "Pwr module pt cable lvad rpl", "standard_charges": [ { "billing_class": "facility", "maximum": 955.35, "minimum": 955.35, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 955.35 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0478", "type": "HCPCS" } ], "description": "Power adapter, combo vad", "standard_charges": [ { "billing_class": "facility", "maximum": 226.28, "minimum": 226.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 226.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0479", "type": "HCPCS" } ], "description": "Power module combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 14780.89, "minimum": 14780.89, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 14780.89 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0480", "type": "HCPCS" } ], "description": "driver pneumatic vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 110901.76, "minimum": 110901.76, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 110901.76 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0481", "type": "HCPCS" } ], "description": "microprcsr cu elec vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 17892.75, "minimum": 17892.75, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 17892.75 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0482", "type": "HCPCS" } ], "description": "microprcsr cu combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 5604.34, "minimum": 5604.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5604.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0483", "type": "HCPCS" } ], "description": "monitor elec vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 23087.32, "minimum": 23087.32, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 23087.32 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0484", "type": "HCPCS" } ], "description": "monitor elec or comb vad rep", "standard_charges": [ { "billing_class": "facility", "maximum": 4483.48, "minimum": 4483.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 4483.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0485", "type": "HCPCS" } ], "description": "monitor cable elec vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 432.9, "minimum": 432.9, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 432.9 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0486", "type": "HCPCS" } ], "description": "mon cable elec/pneum vad rep", "standard_charges": [ { "billing_class": "facility", "maximum": 360.28, "minimum": 360.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 360.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0487", "type": "HCPCS" } ], "description": "leads any type vad, rep only", "standard_charges": [ { "billing_class": "facility", "maximum": 420.31, "minimum": 420.31, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 420.31 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0489", "type": "HCPCS" } ], "description": "pwr pck base combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 20015.46, "minimum": 20015.46, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20015.46 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0490", "type": "HCPCS" } ], "description": "emr pwr source elec vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 865.78, "minimum": 865.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 865.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0491", "type": "HCPCS" } ], "description": "emr pwr source combo vad rep", "standard_charges": [ { "billing_class": "facility", "maximum": 1361.1, "minimum": 1361.1, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1361.1 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0492", "type": "HCPCS" } ], "description": "emr pwr cbl elec vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 109.67, "minimum": 109.67, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 109.67 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0493", "type": "HCPCS" } ], "description": "emr pwr cbl combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 312.22, "minimum": 312.22, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 312.22 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0494", "type": "HCPCS" } ], "description": "emr hd pmp elec/combo, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 264.19, "minimum": 264.19, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 264.19 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0495", "type": "HCPCS" } ], "description": "charger elec/combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 5143.47, "minimum": 5143.47, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 5143.47 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0496", "type": "HCPCS" } ], "description": "battery elec/combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 1846.09, "minimum": 1846.09, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1846.09 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0497", "type": "HCPCS" } ], "description": "bat clps elec/comb vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 576.44, "minimum": 576.44, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 576.44 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0498", "type": "HCPCS" } ], "description": "holster elec/combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 632.48, "minimum": 632.48, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 632.48 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0499", "type": "HCPCS" } ], "description": "belt/vest elec/combo vad rep", "standard_charges": [ { "billing_class": "facility", "maximum": 205.51, "minimum": 205.51, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 205.51 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0500", "type": "HCPCS" } ], "description": "filters elec/combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 37.58, "minimum": 37.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 37.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0501", "type": "HCPCS" } ], "description": "shwr cov elec/combo vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 628.84, "minimum": 628.84, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 628.84 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0502", "type": "HCPCS" } ], "description": "mobility cart pneum vad, rep", "standard_charges": [ { "billing_class": "facility", "maximum": 800.65, "minimum": 800.65, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 800.65 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0503", "type": "HCPCS" } ], "description": "battery pneum vad replacemnt", "standard_charges": [ { "billing_class": "facility", "maximum": 1601.2, "minimum": 1601.2, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1601.2 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0504", "type": "HCPCS" } ], "description": "pwr adpt pneum vad, rep veh", "standard_charges": [ { "billing_class": "facility", "maximum": 844.96, "minimum": 844.96, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 844.96 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "Q0506", "type": "HCPCS" } ], "description": "Lith-ion batt elec/pneum VAD", "standard_charges": [ { "billing_class": "facility", "maximum": 1051.71, "minimum": 1051.71, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1051.71 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "90901", "type": "HCPCS" } ], "description": "Biofeedback train any meth", "standard_charges": [ { "billing_class": "facility", "maximum": 16.17, "minimum": 16.17, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 16.17 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "94016", "type": "HCPCS" } ], "description": "Review patient spirometry", "standard_charges": [ { "billing_class": "facility", "maximum": 24.11, "minimum": 24.11, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 24.11 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "95992", "type": "HCPCS" } ], "description": "Canalith repositioning proc", "standard_charges": [ { "billing_class": "facility", "maximum": 29.33, "minimum": 29.33, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 29.33 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97550", "type": "HCPCS" } ], "description": "Caregiver traing 1st 30 min", "standard_charges": [ { "billing_class": "facility", "maximum": 39.23, "minimum": 39.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97551", "type": "HCPCS" } ], "description": "Caregiver traing ea addl 15", "standard_charges": [ { "billing_class": "facility", "maximum": 20.78, "minimum": 20.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "97552", "type": "HCPCS" } ], "description": "Group caregiver training", "standard_charges": [ { "billing_class": "facility", "maximum": 9.24, "minimum": 9.24, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 9.24 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98966", "type": "HCPCS" } ], "description": "Hc pro phone call 5-10 min", "standard_charges": [ { "billing_class": "facility", "maximum": 10.21, "minimum": 10.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98967", "type": "HCPCS" } ], "description": "Hc pro phone call 11-20 min", "standard_charges": [ { "billing_class": "facility", "maximum": 19.81, "minimum": 19.81, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 19.81 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98968", "type": "HCPCS" } ], "description": "Hc pro phone call 21-30 min", "standard_charges": [ { "billing_class": "facility", "maximum": 28.77, "minimum": 28.77, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.77 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98970", "type": "HCPCS" } ], "description": "Qnhp ol dig e/m svc 5-10min", "standard_charges": [ { "billing_class": "facility", "maximum": 10.21, "minimum": 10.21, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 10.21 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98971", "type": "HCPCS" } ], "description": "Qnhp ol dig em svc 11-20min", "standard_charges": [ { "billing_class": "facility", "maximum": 18.72, "minimum": 18.72, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 18.72 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98972", "type": "HCPCS" } ], "description": "Qnhp ol dig e/m svc 21+ min", "standard_charges": [ { "billing_class": "facility", "maximum": 28.63, "minimum": 28.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 28.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98979", "type": "HCPCS" } ], "description": "Rtm tx mgmt 1st 10 min", "standard_charges": [ { "billing_class": "facility", "maximum": 11.3, "minimum": 11.3, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.3 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98980", "type": "HCPCS" } ], "description": "Rem ther mntr 1st 20 min", "standard_charges": [ { "billing_class": "facility", "maximum": 25.38, "minimum": 25.38, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.38 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "98981", "type": "HCPCS" } ], "description": "Rem ther mntr ea addl 20 min", "standard_charges": [ { "billing_class": "facility", "maximum": 25.04, "minimum": 25.04, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 25.04 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "A4563", "type": "HCPCS" } ], "description": "Vag inser rectal control sys", "standard_charges": [ { "billing_class": "facility", "maximum": 1680.58, "minimum": 1680.58, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 1680.58 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0420", "type": "HCPCS" } ], "description": "Ed svc CKD ind per session", "standard_charges": [ { "billing_class": "facility", "maximum": 110.26, "minimum": 110.26, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 110.26 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0421", "type": "HCPCS" } ], "description": "Ed svc CKD grp per session", "standard_charges": [ { "billing_class": "facility", "maximum": 26.55, "minimum": 26.55, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 26.55 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0438", "type": "HCPCS" } ], "description": "PPPS, initial visit", "standard_charges": [ { "billing_class": "facility", "maximum": 167.28, "minimum": 167.28, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 167.28 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0439", "type": "HCPCS" } ], "description": "PPPS, subseq visit", "standard_charges": [ { "billing_class": "facility", "maximum": 131.63, "minimum": 131.63, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 131.63 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0471", "type": "HCPCS" } ], "description": "Ven blood coll snf/hha", "standard_charges": [ { "billing_class": "facility", "maximum": 11.34, "minimum": 11.34, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 11.34 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0539", "type": "HCPCS" } ], "description": "Initial care training 30 m", "standard_charges": [ { "billing_class": "facility", "maximum": 39.23, "minimum": 39.23, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.23 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0540", "type": "HCPCS" } ], "description": "Train for caregiver add 15", "standard_charges": [ { "billing_class": "facility", "maximum": 20.78, "minimum": 20.78, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 20.78 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G0560", "type": "HCPCS" } ], "description": "Safety plan interven", "standard_charges": [ { "billing_class": "facility", "maximum": 39.18, "minimum": 39.18, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 39.18 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G2250", "type": "HCPCS" } ], "description": "Remot img sub by pt, non e/m", "standard_charges": [ { "billing_class": "facility", "maximum": 7.87, "minimum": 7.87, "payers_information": [ { "additional_payer_notes": "APC", "methodology": "fee schedule", "payer_name": "Aetna", "plan_name": "Medicare Managed Care Plan", "standard_charge_dollar": 7.87 } ], "setting": "outpatient" } ] }, { "code_information": [ { "code": "G2251", "type": "HCPCS" } ], "description": "Brief chkin, 5-10, non-e/m", 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